We had an interesting pre-clinical conference today. Here's the scenario:
Imagine you are a nurse (probably a nurse practitioner, but I don't think that's horribly relevant) working in a family practice (in case you're unaware, this is an outpatient clinic- the kind of place you would go for your routine doctor visits, for a physical, if you had a cold, etc). One of your patients is a 60-something woman on disability with chronic health conditions, including diabetes. In your city (and my city actually does do this), there is a form that the healthcare provider (you) can sign. If you sign it, your patient can get assistance with their electric bill (which would pay for heat, AC, lights, etc). Although this program is designed to help those who cannot afford to pay their electric bill, there is no income requirement that the patient has to fall below to qualify for this assistance. You just have to sign the form. The form must be signed on a monthly basis. The form states that you believe that turning off the electricity in the patient's residence would be detrimental to her health.
Do you sign the form?
A little more information... the patient has a daughter, son-in-law, and grandchild living with her. Both the daughter and the son-in-law work. The residence and electric bill are in the patient's name only.
Now do you sign the form?
One more thing- your patient drops off the form on her way out to Atlantic City (or Las Vegas, or whatever) to spend the weekend gambling in the casinos.
How about now? Would you sign the form?
I have a few thoughts of my own about this scenario, but I am interested to know what others think. It would be interesting to get the point of view of those educated as nurses (if there are any reading) as well as any others. I'm not looking for a right or wrong answer, just opinions. What did you think after the first part of the scenario? Did your opinion change as you learned more about the situation?
19 comments:
Clearly I am not a nurse, nor do I have any sort of healthcare training (unless you count Bio 101, in which I performed rather poorly), but I'd generally say no, I wouldn't sign the form. Firstly, I'm uncertain about whether any of the patient's chronic conditions would necessitate electricity, making it detrimental to the her health if not there. I'd need more clarification on that. Secondly, each additional piece of information generally made me fairly certain that the patient would have the funds to pay for those resources herself. As theprogram is intended to help those who are not able to pay their electric bills, I would find it more useful to put the funds to those who actually cannot pay. By doing that, the system does not get abused, and it ends up being more effective for everyone.
Thanks for your opinion.
Just one thought about that... the electric bill would include heat and air conditioning in this person's case. I would like to add that it gets pretty darn cold here in the winter, and so even a person without chronic health conditions would probably need heat of some kind.
Difficult scenario.
My default answer, without knowing a lot about the woman and the needs of her family, would be to sign the form. If there was a need I couldn't see, and innocent people suffered because I had balked, I wouldn't want that on my head.
I totally appreciate Preethi's point of view as well. In fact, if I could verify that no harm would come from me NOT signing the form, I wouldn't in this case. But I'd have to be very, very sure before I made a decision that could potentially have such harmful consequences.
What decision did your class make? And why?
Okay, I already talked to my wife about this, but I'm not cheating because what I'm saying now is exactly what I said then.
You sign the form, period.
You are the person's healthcare provider. You were presented with a form that at base asks: "Would it be detrimental to this person's health to have the power shut off?" In every instance, the answer is yes -- even if the power didn't include A/C OR heat. (Imagine your life for a minute with no electricity at home and try to argue that it would not have a negative impact on your health.)
If the program is vulnerable to abuse, it is not a healthcare provider's responsibility or place to protect it from abuse. In the case of a nurse, it is his/her responsibility to advocate for the patient and in the case of a doctor it is his/her place to accurately portray the reality of the patient's health situation. If the program needs to be fixed, it should be left to those who instigated it to do so.
I think it would be absolutely indefensible to offer a medically inaccurate opinion (that the loss of power would not have an adverse effect on the patient's health) based on your interpretation of the patient's resources.
I don't see any gray area here.
Very interesting...I'm glad I got to read the other comments and points of view. My only thought is that as a healthcare provider, you are looking out for the current health of your patient, not his comfort. Maybe we're just frugal, but I kinda grew up without really having the heat or A/C on much, and we do with very little now (and could probably easily do without - we'd just throw on a few more blankets ;)). Your duty as the provider is not to ensure that everyone in the city has electricity - otherwise, you would be in city government with training as a healthcare provider to determine what is necessary and acceptable. The nurse's role currently is to ensure the person is in good health - and if he is, then there is no problem. I would seriously worry about there being less money others who truly need the assitance - there is not an unlimited supply of funds. Also, if you know the intents of the program (to help those who cannot afford to pay for electricity), it is part of your job to uphold that. I would certainly advocate trying to determine whether that is something that would be necessary for the patient, but I wouldn't blindly sign it, for wanting the funds to go to those who truly might need it. Otherwise, I could see a situation where many well-to-do people would get a portion of the funds, and there would only be a slight stipend for those who really need it, as there simply would not be enough money to pay for it if you signed the form for everyone.
If you signed it for one person, you would sign it for all, and the system simply isn't (from what I understand) built to pay for the electricity of every person who visits the doctor (thus, virtually everyone).
It didn't include any provision about "will your patient's health be adversely affected to X extent?" It's not about dropping a certain amount, it's about being detrimental at all.
If I were a care provider, I would not ever sign a paper that said "switching off this individual's power would have no negative effect on his/her health," so I just can't bring myself to say that I would ever refuse to sign something that said the opposite.
To me, it's a matter of integrity and being an advocate for the patient. If someone asks me to sign whether I believe something to be true than generally-speaking, I'll sign it. And I definitely would if I am supposed to advocate for a person and I can do so just by signing my name professing that I believe a true statement to be true.
But if you see a problem in the system, it is your duty as a CITIZEN to change it, not as a healthcare provider to subvert or reinterpret it. (Just call me Robert Bork.) If I were worried about the system being vulnerable, I would take it up with the policymakers. I hope that a Police officer who thinks the legal limit in PA should still be .10% instead of .08% would still write out a DUI ticket to someone he pulled over with .09% blood-alcohol level.
I definitely get what you're saying, Zack, but I believe you would not be reinterpreting the system by not signing off - in fact, I believe you would be ADHERING to the system. The system dictates that you sign IF you believe the patient doesn't have the resources to pay for it. In this event, it is subverting the system TO sign it - according to your argument, that is the role of the policymakers, not the health care provider.
The system also dictates that you sign it if you believe it would be detrimental not to sign it. I think where I see the difference is that it would NOT be detrimental to the patient's health to not sign the form if the patient has electricity anyway. He or she would have heat and A/C and all those good things. It would be most detrimental to the largest population to sign unnecessarily - if the person who doesn't need the help gets it and leaves less funding for those who truly do, THAT is the most detrimental.
Perhaps I should add that by bringing this form to you, the patient is saying that she does need help with her electric bill. It's a form of aid for those financially in need. Do you take her word for it? Is it your job/place to decide if she's lying or not? Thanks to Zack and Preethi for an engaging conversation, and you are, of course, welcome to continue that, but does anyone else have any thoughts? Or maybe no one else is still reading our blog. :P
Ohhh...I feel a little silly. I'm obviously not in health care. ;) I totally did not get that she brought you the form...I though it was just something on hand and you had to make the decision for each patient. Duh. Sorry. That definitely makes me a more inclined to sign it.
:)... Well it was my fault for not making that clear in the first place. But even though that is the case, it's still a complex problem with lots of things to think about. That's what I think at least, which is why I was interested in others' opinions.
Hey wait! Can I add my two cents? First off, why wouldn't you sign one of those things for me? :) Let's get on that huh?
Second off, I have to disagree with Preethi. Sorry, but we do have an unlimited amount of money for this... at least our Presidents thinks so, he's printing out Trillions a day! Ba-dah Dum, Chee!
And finally, with all seriousness, I think I would have to pass knowing that she was going on a vacation instead of paying bills. As hard as it is, I would tell her to cancel the trip and rent a good movie instead. If she comes back several times, I would probably sign it later. It's definitely hard, cuz I would wonder where their money would go with no power for a refrigerator for food. Double whammy... so never mind I would sign it! ... wait no.. I wouldn't.... UGH!!! This is why I chose Graphic Design as a major, our biggest worry is getting paid, or what color works best. I'll stick with Graphic Design, thank you!
I think that I would not sign the form in every situation. To say that not having heat/ac would effect health of a patient would apply to almost any of us at any given time in our lives. It is the responsibility of those in a position to sign these types of things to truly determine need. People cannot be taken at face value or believed in every given situation. There are many out there who think that they should get something for nothing and use every measure to get what they want. It is a sad thing when people do things like this and take away from those who truly do need our assistance. It is difficult to be the judge but more often than not it is a bad thing to error on the side of what you may think is kindness. Allowing people to lie, cheat, steal and abuse the systems to help the needy just because you don't want to judge is crazy. We have to make judgments. It is not fun! Pull up your big girl panties and face reality! You are part of the problem if you allow abuse to continue. Thank you very much! Love Mom!
Just to jump back in..... I am pretty persuaded by Zack's argument.
One principle that informs my view on these types of things is that it is better to improperly give aid to 5 people who don't deserve it than to mistakenly deny it to one person who does.
Our society has the wealth and resources to ensure that noone has to go without heat and AC. I would love an efficiently working system of nationalized utilities services, paid for through my tax dollars. I'm not sure our government could pull it off, but it would be great.
The things that are necessary for life - health care, food, shelter, warmth - I consider to be rights. I think they are rights for rich people and rights for poor people. Everyone should have heat in the winter no matter what.
However, I also agree with Preethi's point that there ARE a finite amount of resources BECAUSE our government has not handled this system efficiently. So on some level it is important to ensure that the aid goes to those in the greatest need first. But I'm not convinced its the role of the health care professional to decide that.
In fact, one thing I like about this system is that it takes away the extremely invasive, degrading nature of most of our nation's public assistance programs. Have you ever had to go to a welfare office with two years worth of pay stubs and let someone examine your pitiful income, and then let state authorities come into your home and critique things like the maintenance of your handrails? It's humiliating, and it stems from the deep mistrust our nation has for people asking for assistance.
My impulse is that, if someone asks for help, I am in no place to judge, and I should not deny it. If the priority of the system was verifying need, they wouldn't be having the nurses and doctors sign the form. It would be in the hands of auditors.
I really think there are very few people in our society that are genuinely free-loaders. If I have to encourage their bad behavior to ensure that I don't miss any of the needy, I'd say its worth it.
So, sign the form.
Sorry for the long-windedness.
BTW.... What is YOUR opinion, ShaNae? Did they give you the "right" answer in your clinical?
Also, the word verification says "popatic" which is really similar-sounding to some complex procedure Robert needs to have done to his back molars to avoid a root canal. Like, popactary or something. Lol. Can anyone help me out here?
I didn't even think about it until Robert brought it up, but heat and AC might not even be the biggest detriment to health about not having power.
I dare anyone to lay out a healthy week menu for someone without power and therefore no refrigerator.
No contest. I'd sign it.
Whether or not having younger family members live with her would make her more able to pay is irrelevant. And if it were a sticking point, I dare say that they could as easily be a drain on her resources as a source of income.
Concerning the vacation -- none of my business.
Zack said it best, I think.
Without reading any other comments or posts - Yes, you sign the form. If you believe that it will help this person and their chronic health condition, you sign it. The family and other factors do not matter.
I don't know why nursing programs insist on bringing up these issues to take so much time from learning what nurses really need to know (IMO assessment, pharmacology, and lab values are the pillars of nursing wisdom). These are a social workers issues.
But as a matter of principle, freedom is a function of responsibility and the lady who is going on vacation needs to be redirected.
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