Complexities of care of the elderly

Part 6, version 1

Jack is awaiting surgery. Dr. Edelman had informed the surgical service, and they have found OR time due to a cancellation. They inform the ward, but the consent form has not yet been signed.


Nurse Kim: Dr. Freeburn? It’s Helen Kim on 3B. I need you to come up and get a consent for surgery.

Dr. Freeburn: What! Why me? I just laid down after 24 hours on call. Get whoever looks after the patient. Obviously get the surgeon.

Nurse Kim: Don’t you think I would have if I could? An OR slot just opened up, and the patient is in urgent need of an amputation for a diabetic ulcer. The surgeons are in the middle of performing a bowel resection and this patient is next.

Dr. Freeburn: The diabetic ulcer should have been looked after long ago. He … is it a he?

Nurse Kim: Yes.

Dr. Freeburn: He must have someone in medicine on his case.

Nurse Kim: Dr. Edelman is in his office, and before you suggest it, you know nurses don’t get consents.

Dr. Freeburn: This is crazy. Oh, okay, give me a few minutes.

Nurse Kim: Shake a leg, doctor. The IV is in and the surgeon ordered pre-op sedation. It was given 15 minutes ago.

Dr. Freeburn: Dammit!

  • Dr. Freeburn: Alright, let’s get this over with so I can get back to sleep. Where’s the patient?

    Nurse Kim: In 329, but I’m not sure it’s that simple.

    Dr. Freeburn: What do you mean? Either he says yes or no. Where’s the problem?

    Nurse Kim: Well that’s just it. He has said no, then yes, then no. He has never signed anything. When Dr. Edelman was here yesterday he said the patient had agreed, and that’s why surgery was notified.

    Dr. Freeburn: So Dr. Edelman should have gotten the consent then. Why didn’t he? What kind of ward are you running here anyway?

    Nurse Kim: Sure, blame the nurses. Look, this man is not my patient, and I don’t know why the consent form wasn’t signed. And if he’s sedated now, I’m not sure he is competent to sign it.

    Dr. Freeburn: So I have to decide for a patient I don’t even know. What a screw up! Any family?

    Nurse Kim: He has a daughter. I called her. She’s already on her way home.

    Dr. Freeburn: So tell her to turn around and come back!

    Nurse Kim: She’s 50 kilometres away. Tag you’re it, Dr. Freeburn. Room 329. Get going.


That does not seem to have gone very well. Why not?

“Unfortunately, health care organizations have not evolved as quickly as clinical advances, and the environment of care has evolved into a difficult and complex setting filled with poor communication, unclear policies, role confusion, turf battles, and stressful interpersonal conflicts.”
(Gerardi, 2004).

“There is probably no more significant relationship with a stronger potential for conflict than the physician relationship.”
(Porter-O’Grady, 2004).

These two quotations underline the necessity for collaborative relationships among health-care workers (teams), and the central role the individual physician plays in these relationships.

Conflict is a normal recognition of difference; if we agreed with each other, there would be no conflict. Irrespective of how difficult the situation was, the communication between the physician and the nurse made the situation worse. What communication errors did you observe in the conversation? Consider the possible reasons why the conversation went this way:

  • Values and beliefs (culture)
  • Roles, including perceived boundaries (scope of practice)
  • Goals, both personal and organizational
  • Personality
  • Language, including non-verbal
  • Past experiences

What other sources might be operating? How might this conflict impact the quality of patient care?

Print a copy of the Observation Guide and identify examples of interviewing styles, techniques and attitudes (both effective and ineffective). Next, watch version two of this scene. There are many ways in which the situation could have been resolved. This is just one example.


Next: Part 6, version 2