POTD: No One's Going Home!

Just kidding, Maimo Fam, our patients will be going home, but first, we need to find out where they're going! Are they going to Waterford on the Bay or Garden of Eden? Which one of them is an adult home again? Wait, what's an adult home??

This POTD will hopefully answer those burning questions. This discussion was requested after a conversation of the differences between group home vs. adult home vs. assisted living facility.

Group Home

A group home is a private residence for children, adolescents, young adult men/women, adults, or seniors who either cannot live with their families or are diagnosed with chronic disabilities. Historically, the term "group home" referred to "shelters" housing residents who possess autism, intellectual disability, physical disability, or even multiple disabilities. Group home residents have residence coordinators and will usually come to the ED with an escort. Often times they will have family to make decisions for them.

Adult Home

Adult Homes provide long-term, non-medical residential services to adults who are substantially unable to live independently due to physical, mental, or other limitations associated with age or other factors. Residents of adult homes often have chronic psychiatric conditions. However, residents must not require the continual medical or nursing services provided in acute care hospitals, in-patient psychiatric facilities, skilled nursing homes, or other health related facilities, as Adult Care Facilities are not licensed to provide for such nursing or medical care.

Don't forget to contact the adult home coordinator prior to discharge.

Ex: Garden of Eden (also happens to be an assisted living facility!)

Assisted Living Facility

Assisted living provides long-term housing and care for seniors. Assisted living residents are generally active, but may need support with activities of daily living (ADLs), such as bathing, dressing, and using the toilet. Seniors in assisted living can expect personalized care, nutritious meals, a wide range of social activities to cater to a variety of interests, and a sense of community in a safe, residential setting.

Assisted living is for people who need help with daily care, but not as much help as a nursing home provides.

Ex: Waterford on the Bay, Signature Senior Living, Oceanview Manor

References:

https://www.aplaceformom.com/assisted-living

https://www.health.ny.gov/facilities/adult_care/

https://www.atthecrossroads.com/g/Group-Homes-For-Young-Adults/New-York-NY/

POTD: My Pronouns are She/Her. What are Yours?

This POTD will not be covering topics on gender, sexuality, identity, expression, etc, but I will be discussing anything and everything you have ever possibly thought about pronouns. My goal is to deepen your understanding and hopefully help y'all communicate accurately and respectfully with your friends, families, colleagues, and your patients!

"Proper use of gender identity terms, including pronouns, is a crucial way to signal courtesy and acceptance. Alex Schmider, associate director of transgender representation at GLAAD, compares using someone's correct pronouns to pronouncing their name correctly – "a way of respecting them and referring to them in a way that's consistent and true to who they are.""

Why is this important?

You can’t always know what someone’s pronouns are by looking at them. Asking and correctly using someone’s pronouns is one of the most basic ways to show your respect for their gender identity.

When someone is referred to with the wrong pronoun, it can make them feel disrespected, invalidated, dismissed, alienated, or dysphoric.

It is a privilege to not have to worry about which pronoun someone is going to use for you based on how they perceive your gender. If you have this privilege, yet fail to respect someone else’s gender identity, it is extremely disrespectful and hurtful.

For us in the medical field, we are able to create a safe environment and build rapport with our patients by using the correct pronouns!

What if I use the wrong pronouns?

It’s okay! Everyone makes mistakes from time to time. The best thing to do if you use the wrong pronoun for someone is to say something right away, like “Sorry, I meant (insert pronoun)”. If you realize your mistake after the fact, apologize in private and move on. No need to make it any more complicated than that. By doing that really simple gesture of apologizing quickly and moving on shows the other person that you care, which makes a really big difference.

How do I find out a person's pronouns?

Easy, start by giving them yours! Make it clear, straightforward, and casual — in the same way you’d share what region or city you live in.

Here's some examples:

"Hi, I'm Dr. De Guzman. My pronouns are she/her. I apologize for the long wait, what brought you to the hospital today?"

"HIIIIIIIII, I'm Cat. I'm from Queens, I love fried chicken sandwiches, and my pronouns are she/her. What about you?"

See, super easy!

How is "they" used as a singular pronoun?

"They" is already commonly used as a singular pronoun when we are talking about someone, and we don't know who they are. Using they/them pronouns for someone you do know simply represents a little bit of a switch.

An example:

Let's say you saw a member of the UST grab the U/S from south side, but you weren't quite sure who took it. Dr. Odashima comes by with the remaining UST members and asks if so and so has it. You'd most likely say:

"Oh yeah, they have the U/S." or "The U/S is with them."

In these cases, you're referring to one person with they/them pronouns. See, you've probably already been using "they" as a singular pronoun for your whole life without even realizing it!

What does it mean if a person uses the pronouns "he/they" or "she/they"?

"That means that the person uses both pronouns, and you can alternate between those when referring to them. So either pronoun would be fine — and ideally mix it up, use both. It just means that they use both pronouns that they're listing," says Rodrigo Heng-Lehtinen, deputy executive director of the National Center for Transgender Equality.

The best approach I've read is to just listen to how people refer to themselves or even simpler, just ask!

References:

https://www.npr.org/2021/06/02/996319297/gender-identity-pronouns-expression-guide-lgbtq

https://hbr.org/2021/06/my-pronouns-are-she-they-what-are-yours

https://uwm.edu/lgbtrc/support/gender-pronouns/

POTD: Leaving AMA

What is the best way to handle a patient leaving AMA?

Leaving AMA is not a benign action, both to the patient and the provider. Patients who leave AMA have higher rates of adverse outcomes compared to patients who have completed their medical workup and treatment, and are up to 10% more likely to sue their providers. It is estimated that 1 in 300 AMAs result in a lawsuit. Leaving AMA is a problem that continues to increase in frequency as the years go by; in 1992, 0.1% of ED patients left AMA, and now that number is close to 2% of all discharged ED patients.

Who is more at risk for leaving the ED AMA?

According to Kazimi et al, our most vulnerable patients are the ones leaving AMA. This includes patients with lower incomes, are African American, male, young patients, those with multiple significant comorbidities such as psychiatirc, substance abuse, and HIV in particular, those on public insurance, patients with no PMD, patients with poor social support, and unfortunately unsurprisingly, the uninsured patient comprised almost 1/3 of all AMA discharges documented in the study.

Why do patients leave AMA?

Often cited reasons include personal obligations (children at home, feeding cats, need to go to work), financial concerns, dissatisfaction with care and customer service, distrust of the medical system, wait times, and disagreements with staff.

What is the best way to handle someone leaving AMA?

The most important step is to first try to prevent the AMA discharge. Like the illnesses we treat medically as providers, prevention is key. First step is talking to the patient and figuring out what their reasoning for leaving is. Try to meet the patient where they are- their concerns and priorities may not always match ours. Oftentimes the patient (and the provider) do not realize what options are available that may fix their problem. We have an excellent team of social workers, case managers, substance abuse specialists, and patient reps that can help tackle specific reasons why the patient wants to leave AMA. Additionally, patients may not fully understand the extent of their illness. It is our responsibility as providers to present our reasoning for wanting the patient to stay, and try to find middle ground between our and the patient's goals of care.

But unfortunately, many AMA discharges are inevitable. What should we do when there's seemingly nothing else we can do?

ALIEM has a great article written about AMA discharges: there are 8 components of any AMA that in addition to discussing with the patient, must be documented. Here's a quick summary:

1. Assess the patient's capacity. Assess sobriety, the patient's ability to communicate a choice, understanding, appreciation, and ability to reason.
   

2. Signs and Symptoms: Patient and provider need to agree with their concerns: patient should acknowledge, for example, that their RLQ abdominal pain may be signs of appendicitis.

3. Extent and Limitation of the Exam: Basically detailing that the workup thus far may be incomplete and not representative of the patient's potential illness; labs may be OK, but imaging may still be warranted to rule out appendicitis
   

4. Current Treatment Plan: Discussed what the patient still needs in their workup/reasons for observation/admission, what medications they need, etc.

5. Risks of Foregoing Treatment: patients should be informed of specific complications they may face, including death, infertility, loss of limb, vision, etc.

6. Alternatives to Suggested Treatment: discuss with the patient alternatives to their current and most effective treatment plan.
   

7. Explicit Statement of AMA and Why the Patient Refused

8. Questions, Follow-up, Medicines, Instructions: Do what we can to limit bad outcomes for our patients. Even if the alternative treatment plan is sub-optimal, we are still doing all we can possibly do for the good of the patient. Help arrange follow up as soon as possible and coordinate with their existing doctors if they don't want to stay. Provide oral antibiotics if they do not want to stay for IV antibiotics.

Here's an example I found of AMA discharge documentation:

The patient is clinically not intoxicated, free from distracting pain, appears to have intact insight, judgment and reason and in my medical opinion has the capacity to make decisions. The patient is also not under any duress to leave the hospital. In this scenario, it would be battery to subject a patient to treatment against his/her will. I have voiced my concerns for the patient's health given that a full evaluation and treatment had not occurred. I have discussed the need for continued evaluation to determine if their symptoms are caused by a condition that present risk of death or morbidity. Risks including but not limited to death, permanent disability, prolonged hospitalization, prolonged illness, were discussed. I tried offering alternative options in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient, though the patient declined my options and insisted on leaving. Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation, especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation. I asked the patient to return if they change their mind about the further evaluation and treatment. I strongly encouraged the patient to return to this Emergency Department or any Emergency Department at any time, particularly with worsening symptoms.

Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909809/

https://www.wikem.org/wiki/Against_medical_advice

https://www.uptodate.com/contents/hospital-discharge-and-readmission#H14129862

https://www.aliem.com/proper-way-to-go-against-medical-advice/

https://www.emra.org/emresident/article/lit-review-ama-discharge/

https://www.nuemblog.com/blog/ama

https://www.emra.org/emresident/article/lit-review-ama-discharge/