The COVID-19 pandemic has brought the challenges of complex hospital care to public attention as never before. We've seen nurses, doctors, and respiratory therapists struggling to treat patients in the absence of disease-specific medications and protocols, inventing devices to maximize access to scarce ventilators, and dancing in celebration when their patients were extubated and discharged. Cases of COVID-19 were medically difficult.
As the COVID-19 situation continues to evolve, with better and more accessible treatments, cases will hopefully become less medically difficult. But there are ever more opportunities for non-medically difficult cases to present themselves -- from patients and family members who refuse the vaccine or deny the virus's existence entirely, to the impact of long-COVID and the possibility of multiple hospitalizations for some patients.
This is the kind of "difficult case" my co-researcher, Jay Baglia, PhD, and I investigated with an interdisciplinary group of healthcare workers prior to COVID-19. We recently published an article outlining a clinical communication intervention called the Difficult Case Consultation. The Difficult Case Consultation is a structured conversation that allows diverse clinicians working on a case to share their perspectives in real time, and break free of mindsets that obscure possibilities for improving a patient's care.
Healing the Story
We defined difficult cases as those that involve a lengthy hospitalization or series of inpatient and outpatient encounters (with slow or stagnant improvement of the patient's condition), often include poorer than expected outcomes for the patient, and typically produce high levels of stress for the healthcare workers and patient's family. These cases also impinge on finite resources -- of the hospital and family -- and involve multiple, complex conversations. We also noted that, often, clinicians reported having an intuition early in the case that "things would not go well."
The founder of narrative medicine, Rita Charon, MD, PhD, proposed that it is possible to heal the patient's story even if the patient cannot be cured. As we considered these difficult cases, and the fact that there were no medical errors or complicated diagnoses involved, we wondered whether it was the healthcare providers' stories that needed to be healed.
We began by diagnosing the stories presented by the clinicians on the team using the journalistic tools of who, what, where, when, how, and why.
In each (de-identified) example they shared, we noticed the patient and family were always presented as the central figures -- the "who" -- in the case: as in, "a 73-year-old patient with metastatic ovarian cancer." The what, where, and when of the stories were mostly focused on the care in the hospital setting but were consistently presented in the passive voice: as in, "surgery was ordered" or "MRI was completed but inconclusive." This passive "objective" voice is typical of the clinical case presentation, but we wondered whether it might be interfering with the clinicians' ability to see and communicate their way through to a more satisfying resolution.
Finding a Way Through the Difficult Case
Recognizing there are many ways to tell a story, we decided to try a reframing activity to see if that would open up more possibilities for positive action. We asked: What if the story were retold with the team of practitioners as the main characters of the story (who)? What if the patient's condition was the where and when against which they made their decisions and took action (what and how)?
Here's an example of a typical case presentation:
Before reframing: A morbidly obese patient with stage four ulcer on buttocks and thigh from sitting too long after a fall (who); admitted to medical-surgical floor for antibiotics and wound care over weeks to months (where and when); complex and conflicting communication with hospital staff and patient refusal to address dietary and weight loss issues (what); manipulative family worked actively against hospital staff (how); family was comfortable with conflict, demanded constant attention, and complained regularly despite efforts of hospital staff to meet goals of care (why).
Here's an example of the same case after reframing:
After reframing: Internal Medicine, Plastics, Ethics, Risk Management, Psychiatry, and Physical Therapy (who); undertook prolonged care of a patient with a stage four ulcer (where and when); lack of clear leadership and no coordinated plan led to fragmentation of daily tasks and inconsistent communication with the patient and family (what); shifting of responsibility as attending physicians rotated off hospital service, and lack of accountability of consulting specialists, led to family feeling frustrated and ignored (how); rather than partnering with the patient and family, hospital staff appeased them by allowing patient to refuse physical therapy and dietary recommendations, prolonging the hospitalization considerably (why).
Both stories of this case can be true. What we found interesting is that the first story -- the typical case presentation -- renders the hospital staff as passively reacting to circumstances as the case spirals downward. The second story places a (strategically inflated) level of responsibility onto the clinicians, in order to introduce the possibility that there were missed opportunities to change the course of events and improve the outcomes for the patient, family, and staff.
The practitioners we worked with appreciated sharing their perceptions of these troubling past cases with one another. Furthermore, the process of narrative reframing helped them regain their agency -- a positive outcome that outweighed any feelings of having lost an opportunity.
The Difficult Case Consultation
The Difficult Case Consultation process could be initiated when an attending physician or interdisciplinary team member intuits, "this is not going to go well." To be sure, it is one thing to recognize in hindsight what the healthcare team could have or should have done; it is quite another to perceive and intervene in a case before it unravels. We hope the Difficult Case Consultation might help practitioners who are caring for the same patients to create a shared understanding and return a sense of agency to the healthcare teams on which we all depend.
Elissa Foster, PhD, is a tenured professor and director of graduate programs in health communication at DePaul University. Her research and teaching expertise focus on difficult communication in healthcare contexts, particularly related to clinician-patient communication and medical education. She regularly consults with clinicians and health systems to address communication challenges.
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March 15, 2022 at 03:30AM
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