Portal de Periódicos da CAPES

Treatment of VIPs

2011; Elsevier BV; Volume: 58; Issue: 4 Linguagem: Inglês

10.1016/j.annemergmed.2011.05.009

1097-6760

Alan Jon Smally, B.H. Carroll, Michael Carius, Fred Tilden, Michael Werdmann,

Ethics and Legal Issues in Pediatric Healthcare

Emergency department (ED) medical directors and nursing directors are frequently asked to provide expedited care for very important persons (VIPs), which usually involves placing a patient ahead of others in the queue and finding a room rather than a hall bed. Recently, the concept was questioned by a physician and help from the literature was sought. Discussion of the care of the “celebrity VIP” and “victims of violence” but not of the more mundane “hospital VIP” was found.1Schenkenberg T. Kochenour N. Botkin J. Ethical considerations in clinical care of the ”VIP.”.J Clin Ethics. 2007; 18: 56-63PubMed Google Scholar, 2CCEPCelebrities in the ED: managers often face both ethical and operational challenges.ED Manag. 2006; 18: 133-135PubMed Google Scholar, 3Smith M.S. Shesser R.F. The emergency care of the VIP patient.N Engl J Med. 1988; 319: 1421-1423Crossref PubMed Scopus (27) Google Scholar, 4Guzman J.A. Sasidhar M. Stoller J.K. Caring for VIPs: nine principles.Clev Clin J Med. 2011; 78: 90-94Crossref PubMed Scopus (35) Google Scholar, 5Martin A. Bostic J.Q. Pruertt K. The VIP: hazard and promise in treating “special” patients.J Am Acad Child Adolesc Psychol. 2004; 43: 366-369Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 6Schoolfield D. Treatment of VIPs.J Healthc Prot Manage. 2008; 24: 84-89PubMed Google Scholar Schenkenberg et al1Schenkenberg T. Kochenour N. Botkin J. Ethical considerations in clinical care of the ”VIP.”.J Clin Ethics. 2007; 18: 56-63PubMed Google Scholar suggest that the “I” in the acronym VIP should reflect the word influential rather than the generally accepted important because true importance indicates valid and inherent significance, which may not be the case, particularly with hospital VIPs. With celebrity VIPs, major concerns are that the patient's social status will influence the medical care delivered and that his or her presence in the department will divert resources and space from many patients. Hospital VIPs are locally influential; they may be the physician on staff, corporate donor, hospital administrator, or relatives or friends of any of the preceding. Excluding physicians on staff, their actual care is generally not the issue because often those caring for them don't know them or their influential relative. The issue is ethical: do they deserve to go ahead in the queue at the expense of another patient who will wait longer? Treatment of a celebrity VIP such as a politician, sports star, or actor requires an immediate room or even area of the ED, special precautions related to security visitation and public relations, and prevention of “curbside consultation” from department chiefs and others seeking to either help or bask in the limelight.1Schenkenberg T. Kochenour N. Botkin J. Ethical considerations in clinical care of the ”VIP.”.J Clin Ethics. 2007; 18: 56-63PubMed Google Scholar, 2CCEPCelebrities in the ED: managers often face both ethical and operational challenges.ED Manag. 2006; 18: 133-135PubMed Google Scholar, 3Smith M.S. Shesser R.F. The emergency care of the VIP patient.N Engl J Med. 1988; 319: 1421-1423Crossref PubMed Scopus (27) Google Scholar, 4Guzman J.A. Sasidhar M. Stoller J.K. Caring for VIPs: nine principles.Clev Clin J Med. 2011; 78: 90-94Crossref PubMed Scopus (35) Google Scholar, 5Martin A. Bostic J.Q. Pruertt K. The VIP: hazard and promise in treating “special” patients.J Am Acad Child Adolesc Psychol. 2004; 43: 366-369Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 6Schoolfield D. Treatment of VIPs.J Healthc Prot Manage. 2008; 24: 84-89PubMed Google Scholar Another variant of “VIP syndrome” involves “hall consultations” in which physicians treat VIPs, but also friends, other physicians, etc, in a manner different from the care they would normally provide—that is without a physical examination, detailed history, etc—resulting in the delivery of poor care, also not relevant to the issue of concern here. To better understand whether the practice of expedited care for hospital VIPs is practiced in Connecticut, the query was posed on a listserv survey of the medical directors of 32 of the 33 acute care hospitals in Connecticut to discover whether they approved VIP treatment in their EDs. It was specified that this was expediting care, not providing different care, and did not refer to a hall consultation. More than half responded, and all but 1 endorsed the practice; the other was noncommittal. Many well-thought-out responses are worth repeating: “I ask those who oppose the practice if they have an objection to expediting care for their family or staff's family or friends. We do that all the time without a big moral discussion. This is about control, not a concern for other patients. These folks are part of the larger hospital family.” “Some ask ‘why shouldn’t they see the misery so that they can help us with our issues?' Medical directors see it as a chance to score an easy point with people that can change the life in the ED. It could be valuable to anger them but, more likely, it's not much help.” “I tell them that there are 2 kinds of emergencies: medical and administrative; this one is administrative. If they persist, I tell them that there are political and economic realities in medicine: this is one of them.” “I'd rather have these heavyweights complimenting rather than complaining about my department to the CEO. Plus they can be very influential in terms of projects, improvements, and the flow of capital dollars towards areas they appreciate.” In conclusion, the issue is summarized well by Schenkenberg et al,1Schenkenberg T. Kochenour N. Botkin J. Ethical considerations in clinical care of the ”VIP.”.J Clin Ethics. 2007; 18: 56-63PubMed Google Scholar who says in their recommendations that “special care…is morally unacceptable if it results in worse care for other patients [emphasis added].” The expedited treatment of a hospital VIP results in one patient being pushed back in the queue. It may result in the ED receiving benefits that will help many patients through the influence of the VIP. In Connecticut, many of the ED medical directors view this as analogous to not telling a small child that there is no Santa—vaguely unethical but necessary.