A couple of years ago, we made a family trip to Disney World. While attending the night show at Epcot, we stood on a lovely bridge with wrought iron railings to watch. My then 7-year-old son was leaning into the railing to get a better view, and he put his knee between the rails. He found himself stuck and couldn't seem to get free. He immediately escalated into a panic and yelled to the crowd, "Aaaah! I'm stuck! Somebody call the fire department! Get the jaws of life!" It took a while for us to compose ourselves and stop laughing before we could help the little guy.
In his defense, he at least knew who to call in the event of a true emergency. However, he didn't have the knowledge to discern what a true emergency was. He was a classic example of overuse of resources.
How does this apply to the oncology world? At this past week's Supportive Care Coalition Congress, Diane Meier, MD, director of the Center to Advance Palliative Care, spoke about this very topic. She stated that the system makes calling 911 the only option for patients who call their doctors after hours.
Have you ever called an oncologist's office after hours? You typically hear a recording similar to this: "If this is an emergency, call 911 or proceed directly to the emergency department." Do most patients call the doctor if they don't think it's an emergency? If they're not sure, who do they ask? What inevitably happens? They follow the directions and do the thing that relieves the physician's office of any liability.
But is this the best outcome for all concerned? Probably not. The patient who calls 911 or proceeds directly to the emergency department generally succumbs to overtreatment and unnecessary admission. Painful tests are performed by an ED physician who is not an expert in cancer symptom management and is looking for some other root cause for the symptom -- ruling out everything only to arrive at the conclusion that this is truly the result of cancer treatment.
Uncontrolled pain, uncontrolled nausea, or other side effects of cancer and its treatment are certainly emergent concerns for the person experiencing them. But they often don't necessitate emergency room treatment or hospital admission. More often than not, the patient doesn't want that either. The patient wants to be comfortable and able to do the things on a bucket list, or to finish treatment and optimize the chances for a cure.
How do we keep that patient at home? We have to change the system. The dynamic of referring a patient to ED to avoid liability, and the ED performing every test imaginable to avoid liability, needs to change.
Patients need to be able to access a telephone nurse after hours through home care services that allow maximum independence and optimal symptom control. Unfortunately, you have to be homebound to qualify for reimbursable home care services. Without that, you are left after hours with an answering service message that advises you to overtreat a very manageable problem by dragging yourself to the emergency room in the middle of the night, accompanied by a fatigued, beleaguered spouse, only to get admitted for several days. You find out it's just pain after all. In the meantime, you have 14 diagnostic tests before your pain regimen is adjusted. Your stress level escalates, and your life is disrupted.
All you really needed was what my son received -- a calm voice saying, "It's OK. Calm down. Take a deep breath. Straighten your leg." My son breathed a sigh of relief and walked around on his now free leg with exuberance. You'd have thought he had narrowly escaped death.
Someday, wouldn't it be great if, instead of saying, "Call someone else," the healthcare system could just say, "It's OK. Calm down. I can help you"?