HOUSECALLS 9: An End-Run Around the Rules.

Are there times when rules should be broken, or just ignored? This can be hard to decide, rules being rules and presumably set for everybody and for good reason. But one of rules’ limitations is that there may be exceptions. Generally for example it’s a pretty good idea to tell the truth, but there are times when it’s the most harmful thing in the world.

Here in our health region a variety of helpful programs is available, and one of these is intravenous treatment at home. This could include antibiotics, chemotherapy, and just fluid replacement. Somebody along the way has recognized that there may be situations where it’s better and safer to give substances directly into someone’s bloodstream without having that person in the hospital.

Cut to the street, I’m seeing Mrs. W. at home accompanied by a family practice resident and Mrs. W.’s son, who is a retired physician. This dear 97-year-old Chinese lady has had several infections in her leg, and on this occasion the first simple drug we gave her didn’t work, and two more wide-spectrum (and expensive) others caused her to lose her appetite and (one of them) to start vomiting. The leg infection, evidenced by a warm red swollen calf, is maybe 30% better, but a long way from being cured. The next reasonable option? Give a strong antibiotic intravenously to get a higher blood level and maybe avoid digestive side effects.

Her son has concerns. She was in the emergency room a couple of years ago and their intravenous treatment program seemed the best way to treat her at that time as well. Unfortunately, she had to go back to the hospital daily for 10 days, and each time both family members sat waiting for a couple of hours, sometimes as long as five hours.

The home intravenous program offered by the region also has some limitations. The patient has to go to the emergency room, be evaluated by an emergency room physician, wait to see an infectious disease specialist, have the intravenous medication chosen and started, if it’s deemed appropriate, and then maintain a central intravenous line and be given slow intravenous injections by home care nurses every day at home. Our very cooperative and knowledgeable medical family member wasn’t happy with this arrangement either because of the red tape and possibility of getting no treatment at all.

When I contacted our home-care program nurses, all very well known to me and fabulously practical well-informed clinicians, it was clear that as employees of the region any home intravenous injections they gave would have to be done through that same somewhat awkward policy-driven system. So what to do?

“I can give the medication myself,” said the son, who had spent his career doing just that kind of thing in an operating room. My resident and I were also willing to pitch in and help. I got ahold of a local pharmacy which dealt in intravenous supplies and medication, prescribed the drug, and requested the supplies.

Next day I got a call from the physician son that the intravenous tubes, vein catheters, and other supplies delivered were deficient. Because I’m known in the emergency room due to a part-time job I have there I was able to cadge the necessary supplies and get them out to Mrs. W’s apartment.

We are now four days into the treatment with no complications and some early improvement in the infection.

There could be questions about all this. Should a son be treating his mother? Well, he doesn’t really have his physician’s hat on. He’s functioning as a family member giving a treatment he happens to be able to administer, prescribed by me and under my supervision. Should a senior member of the medical community be flouting its safety rules (to say nothing of publishing his rash behaviour)? I’m not proud of doing that, but on the other hand if safety is the issue I think risking the delays and possible hospital admission Mrs. W. might have faced carry at least as much danger for her as giving IV medication in an unauthorized but technically correct and expert manner.

Sometimes, just once in a while, it’s in the patient’s interest for us to do the reasonable as opposed to the correct thing. I don’t have any problem with that.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 30 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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2 Responses to HOUSECALLS 9: An End-Run Around the Rules.

  1. Wonderful post, John! I like the creative problem solving and I wish our system was more flexible to allow for more of these answers. I find that my own perception of “the system” and expectations change from location to location; in Nunavut, there is a lot more freedom to do whatever it takes to get the patient the best care possible. It may not be the “Vancouver” standard of care, but keeping someone in their home, with their family caring for them is a victory in my books.

    On the other hand, I find when working in Vancouver that I let the (perceived) expectations hamper me. “It’s not the way we do things,” “the system doesn’t allow it,” or “the standard of care here is X,” are things I find myself thinking/saying. It’s a bit shameful to be so repressed! Any advice (courage?) for young practitioners who feel a bit cramped by the looming presence of “the standard of care” ?

    Jessica Otte (MD)

    • John Sloan says:

      Thanks for taking the time to comment Jessica. Nothing comes without a price tag, and the order and predictability we get (or at least imagine) from policies, procedures, rules, and clinical pathways costs us dearly in terms of freedom. Most authorities however accept that there may be exceptions. I have always found that “transparency” (i.e. telling everybody involved exactly what you are doing or not doing and why), getting patients’ and families’ permission, and careful logical documentation go a long way toward properly and acceptably breaking certain rules. It takes time (like a decade or two) to develop the kind of trust that results in a reputation for being practical and exercising reasonable common sense.

      Good luck, and again thanks.

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