What Happened to Provider Communication Etiquette?

Nurse practitioner experiences poor provider etiquette when making medical decisions for her father who was hospitalized following COVID-19 infection.

In September 2021 amid the COVID-19 pandemic, my father became another statistic. Even though my father was 76 years of age and in good health, he suffered from severe symptoms of COVID-19 with a precarious hospital stay. Nothing prepares you for having to make lifesaving medical decisions for a parent.

I was looking for guidance and hope from my father’s health care providers, however, to my dismay, the opposite occurred. When is it okay for a health care provider to deliver bad news bluntly? How about adding their biased opinions to add a final nail in the coffin? Unfortunately, I received devastating news from an intensivist physician about my father 5 days after his hospital admission in a rude manner.

My father arrived at the emergency department (ED) after 10 days of experiencing COVID-19 symptoms. He was unvaccinated. He would tell me, “I am not against vaccines, I just don’t get them.” In the ED, he was in respiratory distress with hypoxia. He was then admitted to the Step-Down Unit and placed on heated high-flow oxygen. He was not allowed any visitors at this time. I would call the hospital every shift for an update. His respiratory status waxed and waned over the course of 5 days. By the fifth day, I received the dreaded phone call that intubation was imminent. However, my father was refusing the ventilator option. He was on bilevel-positive airway pressure (BiPAP) and developing lethargy. At this point, I demanded that my stepmother and I be able to see him.

Prior to entering his room, we had a meeting with the intensivist. He said that my father was in bad shape and very sick. Then he said, “if you place him on a ventilator he will die, and you will make him suffer and he will be in pain.” He also stated, “all of his [COVID-19] patients on the ventilator never come off” and that “your best course of action is to give him a morphine drip and let him go today.” On what basis can this physician say without a shadow of a doubt that my father will die if placed on a ventilator? That statement seems a bit presumptuous.

Then, he preceded to ask if we were vaccinated. I was fully vaccinated, however, my stepmother was not and just recovered from mild COVID-19 symptoms prior to my father’s illness. The intensivist then went on a tangent about all of the unvaccinated patients he has seen die and that my stepmother should go tomorrow to get a vaccine. He didn’t understand why anyone would not get the COVID-19 vaccine and stated it was irresponsible. I am not denying some of what he was saying is not true, however, it was the tone of his voice and the persecutory nature of his delivery.

After the intensivist left the room, I immediately called a physician colleague and her husband who is a hospitalist; both also work for the same health care system that my father was in. I told them about what transpired. They were flabbergasted by what the intensivist told me and disagreed. I was thankful to have a sounding board with my peers. Consequently, I was able to gather my thoughts and develop my approach regarding medical decisions for my father. In the end, he was on a ventilator for 10 days and then was successfully extubated. He then suffered a pneumothorax and required 2 chest tubes. His respiratory status continued to decline and was placed on hospice and passed away.

Because I am a nurse practitioner (NP) at the same health system where my father was a patient, I felt less inclined to file a complaint against this provider. I have wondered if this physician is suffering from provider burnout related to the pandemic.1 The past 3 years have been stressful and filled with uncertainty for me as a provider and personally. Working in skilled and long-term care facilities has been a challenge. COVID-19 infections have consumed my facilities over and over during the pandemic. I often had to deliver bad news to residents’ families either due to COVID-19 or other illnesses in the geriatric population. My goal in providing care is centered on compassion and understanding. Even in stressful situations or a bad day, I would take the time to listen to family members’ concerns, explore all options, and develop a plan of care that the family was comfortable with.

Communication Skills

Bray et al described compassion as the core value and most important ethical principle for health care professionals.2 Interestingly, 36% to 64% of patients in the US have experienced unkind, rude behaviors from health care workers.3 Sehouli surveyed more than 1000 physicians and medical students and found that only 31% felt they had suitable communication skills when breaking bad news.4

You do not need good communication skills to become a health care provider. Providers must successfully complete a curriculum and clinical experience to be awarded a degree and must pass a board certification to practice. Education alone costs time and money. The investment in effective communication training would also cost time and money; therefore, communication skills are not always a priority for providers. However, good communication skills that exhibit professionalism and empathy will lead to better patient satisfaction and strengthen provider-patient relationships.

My experience has stimulated my inquiry on this subject. The literature, studies, and curriculum on breaking bad news are limited. DeFoor et al evaluated 64 medical students who shadowed chaplains as a method to provide compassionate care training and analyzed their reflections after the experience.5 All the medical students supported the shadowing experience and had a better understanding of pastoral and compassionate care. I believe this study shows promise in ways to incorporate improved communication with empathetic care for providers.

I have more than one experience with poor communication in health care. I have always worked hard on providing compassionate care to my patients and families. My hope moving forward is to encourage faculty across NP, PA, and medical curriculums to incorporate communication etiquette and compassionate care training.

Bernadette Sherman, DNP, FNP-C, GS-C, is director of Clinical Education and associate professor in the graduate nursing program at Carlow University in Pittsburgh, PA. She also practices as a nurse practitioner in geriatrics, male hormone replacement, weight loss, and telemedicine.

References

  1. Rabow MW, Huang CS, White-Hammond GE, Tucker RO. Witnesses and victims both: healthcare workers and grief in the time of COVID-19. J Pain Symptom Manage. 2021;62(3):647-656. doi:10.1016/j.jpainsymman.2021.01.139
  2. Bray L, O’Brien MR, Kirton J, Zubairu K, Christiansen A. The role of professional education in developing compassionate practitioners: a mixed methods study exploring the perceptions of health professionals and pre-registration students. Nurse Educ Today. 2014;34(3):480-486. doi:10.1016/j.nedt.2013.06.017
  3. Dignity Health survey finds majority of Americans rate kindness as top factor in quality health care. News release. Dignity Health; November 13, 2013. Accessed January 3, 2023. https://www.businesswire.com/news/home/20131113005348/en/Dignity-Health-Survey-Finds-Majority-of-Americans-Rate-Kindness-as-Top-Factor-in-Quality-Health-Care
  4. Eppinger, U. The art of breaking bad news (and good news, too). October 25, 2022. Accessed December 20, 2022.
  5. DeFoor MT, Moses MM, Flowers WJ, Sams RW 2nd. Medical student reflections: Chaplain shadowing as a model for compassionate care training. Med Teach. 2021;43(1):101-107. doi: 10.1080/0142159X.2020.1817880

This article originally appeared on Clinical Advisor