Complexities of care of the elderly

Part 6, version 2


Nurse Kim: Dr. Freeburn? Well this is Helen Kim on ward 3B. I’ve got a problem here and I don’t know who else to call. Can I tell you about it?

Dr. Freeburn: What do you want? I was just getting to sleep after 24 hours on call. Isn’t there anybody else?

Nurse Kim: I’m so sorry to wake you up. But let me explain. We have a patient here, Jack McTeer, who has a gangrenous leg and needs an amputation. The surgeons just found a slot for him, and called to get him ready. Dr. Edelman is his hospitalist, but he’s in his office, and the surgeons are in the OR with another patient.

Dr. Freeburn: So what do you need from me? A physical, check labs, or what?

Nurse Kim: He has no signed consent form. I think it was just missed between shifts. I just came on and discovered it was missing as I was getting him ready.

Dr. Freeburn: Well, that should be straightforward. I’ll just …

Nurse Kim: No, no, it’s not. He has been given pre-op sedation ordered by the surgeons, and in the past he has wavered about consent. I’m not sure he will be truly competent just now.

Dr. Freeburn: Good grief! I hate these messes. Okay, I guess I have no choice. I’ll come up and we can try to sort it out. Give me a few minutes.

Nurse Kim: Thanks, but better come as soon as you can, so he won’t be asleep.

Dr. Freeburn: Okay. I’ll hurry.

  • Dr. Freeburn: Are you Nurse Kim?

    Nurse Kim: Oh yes, I am.

    Dr. Freeburn: I’m sorry I was so short with you over the phone. I‘ve had a lousy 24-hour shift.

    Nurse Kim: Oh that’s too bad. But if we could find any other way to handle this, I’ll send you right back to bed.

    Dr. Freeburn: So why don’t we have a consent form? If he’s been waiting for surgery it should have been done.

    Nurse Kim: Well he wavered about consent. Psych has seen him, and he said that he’s no longer confused so he could decide about the procedure. But I’m not sure he’s truly competent just now.

    Dr. Freeburn: Oh really?

    Nurse Kim: Well … I mean, he has said no then yes, then no, and he has never signed anything. When Dr. Edelman was here yesterday he said he had agreed and that’s why surgery was notified.

    Dr. Freeburn: What about family? Can they help, especially as I don’t know this patient?

    Nurse Kim: He has a daughter. She left here a while ago and is on her way home. I called her and she couldn’t get back for an hour or more. But between you and me, I’m not sure how well her and her father get along anyway.

    Dr. Freeburn: Oh boy. Well, I’d better go talk to him. Can you come with me since he doesn’t know me?

    Nurse Kim: Sure. Just follow me.

    Dr. Freeburn: Okay.


Note how different this scene is from the previous one. They start out in the same frame of mind, but quickly change their behaviours. How does this happen? Although each scene might achieve the same result, which one demonstrates the most efficient and quality health care? Also, how might medical error be more likely in the first scene?

This is an example of how conflict, if unresolved, can create a toxic and inefficient work environment. For another illustration of conflict, review the “Communications challenges” section of the “Communications Skills Module.”

Both Jack and Dr. Edelman confirmed previous verbal consent to the surgery. Dr. Freeburn deemed Jack competent and Jack signed the consent form. The amputation was done five weeks ago. The social worker has visited Jack to assess the feasibility of Jack returning home.



Next: Part 7