What Really Matters In The End?
May 19, 2017 -
Author: Tony McNamara, CEO, Cork University Hospital Group
I have just finished reading Brigham surgeon Atul Gawandi’s incredibly thought provoking book “Illness, Medicine and What Matters in the End” which among many various themes explores what really matters as we approach the end of life. In a sense he challenges us to reflect on what ought to be our “North Star” in terms of relative importance of values that we hold dear and our guiding philosophy as we go through life.
I realise as I reflect on its’ themes, that I work in an oftentimes apparently chaotic, randomised health system that offers opportunities to deliver, on a daily basis, the best and worst of behaviours in an extremely dynamic acute hospital setting. The incessant pressure to manage c. 1,300 patients per week attending our Emergency Department (ED), one third of whom require admission, strains our collective value systems as we constantly juggle elective and emergency care, patient flow and competing demands for resources, while trying to be equitable, scientific and just simultaneously.
I find myself increasingly drawn into the realm of language such as “delayed discharges”, “inappropriate placements”, “suitable for long term care” and other dispassionate language and behaviours with which I am increasingly uncomfortable. These discussions frequently conflict with the wishes of patients and their families who themselves oftentimes have differing needs or intentions and the dialogue is overlaid with many differing family and societal interests.
In the end, the individual patients’ own wishes, it seems to me, are often sacrificed in the interest of the extended family or the health system and patients end up in nursing homes or other care settings when they would far prefer to be in their home setting. That represents a failure in my view and we owe it to individual patients to do what they most often want – to go back to their homes and to be supported there. Perhaps indeed it is our Home Help programmes that should be getting increased funding to enable patients live at home rather than in other settings where this is possible.
It is as if the system has begun to dehumanise me and I struggle to manage the competing dilemmas of trying to do what is best for every patient. I rationalise in my own mind that maximizing discharges is essential in order to facilitate the admission of equally (and perhaps more) needy patients awaiting admission as emergency or elective cancer patients but I do so from an emotional distance that gives me the benefit of anonymity in that decision making or rationing and therefore in some way allows me to retain some distance from the decisions that need to be taken.
I get solace and comfort on the other hand from the thousands of deeds and words given by our caring staff to patients hourly, daily and weekly and I hope that our philosophy and culture of caring, compassion and respect continues to prevail in everything we do. We are incredibly fortunate to work in a care setting where we have the daily opportunity to carry out a myriad of small acts that can and do make a meaningful difference to the lives of others.
In the midst of the “noise’ that goes on in our hospital simultaneously managing conflict, budgets, competing priorities, politics and the allocation of resources, we should all pause to reflect on what is truly important in life – friendship, respect and collegiality – and those many other great values that my parents and our parents taught us. For those gifts I will personally be forever grateful and the challenge they set me remains a daily one that I am privileged to accept.
The real world in which we live and work is not going to change and I believe we have to reflect on how we can adapt to it to bring to bear those values that will help to improve the lives of those less fortunate than ourselves. Mr. Gawandi has caused me to reflect on what I can do within the realm of my areas of responsibility to behave in a more reflective manner mindful of the real life challenges that individuals and their families face, oftentimes unexpectedly and without warning.
J.A. McNamara, Chief Executive Officer
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