Weekly Tidbit #3 - Reflections on Collaborative Care

by Paul Uhlig


Hi Everyone,

Tonight is the third Weekly Tidbit of the newly created Collaborative Care Learning Network.

This Tidbit continues a series of firsthand perspectives on collaborative care. In earlier Tidbits we heard the reflections of a patient's wife, Vicki, and of Noni, the chaplain on the care team. Tonight's Tidbit reports my own reflections about the care of this patient, as the surgeon assuming his care.
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Paul – surgeon – reflections on collaborative care

            “When I started my time on call, I knew there had been difficulties communicating with the family, and concerns about what was causing the patient's deterioration. When we got to his room for rounds, the distress of the family was readily apparent. In fact, everyone in the room was on edge, not just family members. The patient was not doing well. He was restless and agitated, fighting the ventilator. Vicki and her daughters were present, but a son--who is a nurse--was not there yet and was not expected for a while.

            I decided simply to trust the collaborative care process. We began by forming our circle around the patient’s bed, taking care to invite Vicki and her daughters to join us as part of the circle. Several of us sat in chairs, and we pulled up a chair for Vicki so she could sit close to her husband and hold his hand. We took time to introduce ourselves, and encouraged Vicki and her daughters to join in the introductions. I said what we usually say, “This is our collaborative rounds. The purpose is to be sure we are all on the same page, and that all of us, together, are all taking the best, safest care of your husband that we can.” But I also added, “I know there have been some communication concerns over the past several days. I want to emphasize that we will take whatever time is needed today to make sure every question or concern is answered and addressed.” Vicki and her daughters were still very tense, probably angry, but they were willing to go along with the process.

            We then patiently went around the circle, listening to Vicki and her daughters, considering the observations and suggestions of everyone there, reviewing each lab and medication, and checking and verifying anything that people seemed uncertain about or where there were conflicting opinions or observations. It didn’t take all that long, probably about twenty minutes, but impact was notable. Within just a few minutes after we began, the tension in the room was notably less. There were several unresolved questions, most significantly some increasing wound drainage and a concern for a wound infection as the cause of the patient’s deterioration. Plans were made for a CT scan, and possibilities were discussed including that it might be necessary to go back to the operating room.

            Near the end of this discussion, Vicki’s son arrived. The anxiety in the room was higher again after he arrived, and we handled that by simply starting over, from the beginning. We went through the entire process again, from the introductions onward, taking special care to include him. With him present and participating, we reviewed again what was known and not known, and talked again about the possibility of a wound infection. We included the family in all of the decisions and all of the uncertainties. Plans were written down on the white board and carefully reviewed with clear promises about how follow up would occur later throughout the rest of the day. We also took special care to ask the family their wishes and the patient’s wishes about continuing care if that meant reoperation or continued time on the ventilator. As we did this, just as before, the tension in the room seemed to melt away.

            I might add that the collaborative care process was helpful for the entire care team, not just for the family members, and especially helpful for me. Several people had concerns about various aspects of the care, including a pressure ulcer that was developing, wound drainage that had been increasing, concerns about sedation and restraints, nutrition and bowel function, and many other nuanced details about his care. It took several times around the circle for all of these concerns to be brought forward. As part of guiding the rounds process, we held this conversation open for additional observations and recommendations from everyone present. I am sure the decisions we made, including the decision later that day to return to the OR, were better decisions because of these discussions, especially the suggestions of the physician assistant who had been involved in the patient’s care throughout his stay. The combined insights of everyone there made it easier to see a big picture of how the patient’s condition was changing. I’m not sure we would have made those calls as early or as correctly, if it had not been for this process. And, trust was restored.

            I am grateful, as I read Vicki and Noni's thoughts, that we do this. I believe deeply in collaborative care. These stories help me remember why it matters.”