Portal de Periódicos da CAPES

Ethical Challenges of Caring for VIPs in the Rehabilitation Setting

2012; Wiley; Volume: 4; Issue: 7 Linguagem: Inglês

10.1016/j.pmrj.2012.05.006

1934-1563

Steven Kirshblum, Gail M. Solomon, Rebecca Brashler, Kristi L. Kirschner,

Diversity and Career in Medicine

Much has been written about the particular challenges of caring for VIP (very important person) patients in health care. The recent tragic death of Michael Jackson highlights how serious errors in medical judgment and deviations in standards of care seem more likely to occur with high status, influential, and wealthy patients. Hospital staff often express angst about observed inequities in treatment between 2 patients who have the same medical conditions but markedly different social status. How do we reconcile this differential treatment in light of expressed professional values of caring for all patients? Are the words of the Declaration of Geneva merely aspirational, that is, to "not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient"? The media pose another set of challenges for health care providers in caring for high-profile patients. For people who live in the public eye, the media's desire for information can be insatiable. Yet, patients have a fundamental right to privacy. Trying to ensure that right and protect from leakage of information when health care institutions literally have hundreds of employees who have potential access to patient information is daunting. Legitimate questions about whether there are limits to the right to privacy have also been raised when the patient, such as an elected official, has a fiduciary interest to the public. To understand perspectives on differential care, I have invited commentators from 2 high-profile but geographically disparate rehabilitation hospitals to help us consider these questions: Steven Kirshblum, MD, medical director, and Gail M. Solomon, vice president of corporate communications, Kessler Institute for Rehabilitation, and Rebecca Brashler, director of global patient services, Rehabilitation Institute of Chicago. I plan to do a follow-up column on this topic in the near future regarding a specific VIP. As always, I welcome your comments and thoughts in response to this column, or future topics you would like addressed. As rehabilitation providers, we aspire to treat all of our patients as VIPs, or "very important patients," who all receive the same high level of quality care, advanced treatment, and service excellence. But, in reality, there are exceptions. Although some would prefer to deny that this occurs, many hospitals fall prey to the "VIP syndrome," when a patient's social or political status, or the perception of it, leads to changes in the usual behaviors, administrative protocols, and clinical practices that in turn can impact outcomes [1-3]. At our facility, as in many inpatient rehabilitation hospitals and units around the country, we treat a significant number of patients who warrant specific VIP designation. Some, for example, are high-profile individuals who have "celebrity status" in the fields of business, government, education, entertainment, and sports. Others are family members or colleagues. Still others find themselves in the spotlight due to the circumstances surrounding their injury, which include, for example, some of the police officers, firefighters, and members of the military we have treated, as well as many private citizens who are suddenly thrust onto the media stage. Caring for a VIP may create pressures to change usual hospital practice, but it is essential to resist changing those aspects that have proven effective for the facility. Given the added visibility and range of challenges a VIP may bring to the inpatient rehabilitation hospitals and units, the first question often raised is whether or not to admit the particular patient. Our response is always predicated upon one factor: does the individual meet the criteria for an acute rehabilitation admission? All prospective patients, including VIPs, must meet the same criteria for admission based upon their diagnosis and impairments, prognosis, and the ability to both participate in and benefit from the rehabilitation program. The decision must be based solely on medical appropriateness and our capacity to meet the individual's needs and not be influenced by the potential for local, regional, or national attention. Similarly, discharge planning is a complex issue that must follow standard clinical protocol and is best addressed through consistent communication between the team with the patient and family. As we all know and teach, progress in rehabilitation is best achieved through the coordinated efforts of an interdisciplinary team led by the physiatrist and focused on the individual needs and goals of the patient, which raises the question of who should lead and who should be part of the team. Often, there is pressure on the medical director or department chair to assume the leadership role in high-profile cases. This pressure may come from the patient and/or family, or even from the hospital administration. However, it is our view that the lead physician should be the clinician who has the most expertise in treating the particular diagnosis, regardless of seniority. We also routinely allow house staff (eg, residents and fellows if they are on the physician's service) to participate in the care of the individual to maintain hospital routine and to facilitate off-hour care. When treating high-profile patients, the rehabilitation team typically expands to include other staff that can help to ensure that any additional privacy, security, and communication needs of the patient and his or her family are met. For example, some VIP patients may have a need for police protection or a personal security detail (eg, for a politician) that will need to work in concert with the hospital's own security department. Some patients, their families, or advocates may initially request a private setting for therapy. We usually encourage patients not to isolate themselves, but we will make such accommodations if they feel adamant about this. In time, however, we have seen almost all of these individuals transition into the main gyms and receive treatment alongside others with the same diagnosis. In his book Still Me [4], actor Christopher Reeve acknowledged this, writing, "Little by little, as I became more comfortable at Kessler, I began to emerge from my isolation. I started to visit with other patients and they came to visit me. I met people from every walk of life, of many nationalities and ages … . And I found myself connecting with them in ways that I would never have thought possible. I had been separated from the other patients by a wall of security that somebody thought I needed because of my celebrity status, until one day I said, 'This is ridiculous. I don't need these guards.' I started interacting with the other patients. I was becoming less resistant to being one of them." Particularly when dealing with a VIP, the hospital's communications or public relations (PR) officer becomes an integral member of the rehabilitation team. This is the individual responsible for maintaining the often delicate balance between protecting patient privacy as dictated by both HIPAA (Health Insurance Portability and Accountability Act of 1996) and hospital policy, and providing access to information on matters of public record or individuals who are considered newsworthy. As the point person or, in some instances, the gatekeeper, the PR officer will work closely with the patient and family as well as any personal publicists, business managers, law enforcement officials, or others who may be involved. He or she can offer guidance to patients and families unfamiliar in dealing with the media, field inquiries and coordinate any statements or interviews, and facilitate press conferences when and if appropriate. In addition, the PR officer can mentor the physician and members of the treatment team who may be requested to participate in media interviews. Protecting the privacy of all patients is paramount, and, when dealing with VIPs, additional vigilance is required. All too often we read of how celebrities' confidential records were copied or otherwise exposed, particularly in this age of social media. How easy it is for someone to capture a photograph with a cell phone and post it online for all to see or to "tweet" something that violates the privacy of a patient. As with all hospitals, we have strict policies in place to avoid compromising any patient's privacy in accordance with HIPAA regulations. That message is reinforced through regular staff education and is discussed with the team and staff in advance as well as during the stay of any such admission. We are also well aware that a breach of privacy may come from another patient, family member, or visitor who happens to recognize the VIP in a therapy gym or public area of the hospital. To keep any such discussion, gossip, or media leaks to a minimum, we remind patients about the importance of confidentiality and the respect of an individual's privacy. Certainly, along with protecting the privacy of the individual identified as the VIP, it is essential to maintain these rights for all patients in the facility. When media interviews and special visitors occur, the hospital should prepare accordingly so that these activities do not impact anyone else in the hospital, including other patients and their families as well as staff. It is important to remember that VIPs choose to come to our facilities not because we have successfully treated other VIPs but because we successfully treat hundreds of patients each year. A patient's profile does not change our treatment policies or protocols. After all, if we were to tamper with our programs of care and treatment, then we would alter the very things that drive our success and the outcomes of our patients. Rather, we must maintain our flexibility to accommodate special needs and requests. This is often discussed with the family and patient advocate ahead of time to make all aware of the expectations. Lastly, there is no doubt that the presence of a VIP intensifies the focus and, in turn, the pressure on an individual hospital. But, it also offers an opportunity to demonstrate not only our own clinical and operational excellence but the very importance of the field of physical medicine and rehabilitation. In other words, working with these "very important patients" and the attention that it may bring is the time for us to reinforce the quality of care we provide … and the chance for us individually and as a field to shine. Although we do not have kings and queens in the United States, many would argue that we treat our rock stars, movie actors, politicians, and professional athletes like royalty. Furthermore money, even in the absence of fame or talent, can buy a lot of attention, good will, and "royal" treatment. Because rehabilitation hospitals exist within this societal context and not in a vacuum, it is not surprising that we, too, must grapple with questions about differential care based on social status or socioeconomic class. The more meaningful question is not, do we as rehabilitation professionals provide differential care based on social status? Of course we do. But, do we provide differential care in a manner that seems just or fair? Can we go home at the end of the day confident that nobody was harmed by the way we doled out precious rehabilitation resources? Are we providing decent, humane treatment to the most needy and vulnerable members of our communities? The airline industry has done a pretty good job of providing fairly for their passengers without any pretense of maintaining a "veil of ignorance" about passenger status. They publically acknowledge that some passengers, those with money or those deemed to be "good" customers get rewarded with "platinum" or "gold" status labels. They get access to special lounges, shorter lines, wider seats, better food, and a higher flight-attendant–to–passenger ratio. They even call it "first class," and there is no attempt to pretend that they treat everyone equally. But they have also carefully defined elements of air travel that constitute basic or safe treatment. Everyone gets a seat belt. Everyone gets an oxygen mask. Everyone gets a flotation device in his or her cushion. There are clearly marked exits in coach as well as in first class cabins. There is complete transparency about the minimal standard of acceptable air travel arrangements as well as what constitutes "VIP" treatment. Passengers know up front what services they can expect to receive and what services others with more status will receive. Most are also mindful of the fact that there are some who will not fly at all but will have to take the Greyhound bus or forego vacations altogether. No doubt, health care is fundamentally and dramatically different than travel, but I think we can learn from this example and from the transparency that exists in the airline industry. If rehabilitation providers thoughtfully defined what constitutes a minimally acceptable or "safe" rehabilitation experience, then our angst about VIPs might be reduced. But this would require us to be much more open about these issues, and I find that many in our profession are reluctant to go there. Many of my colleagues cling to their desire to say "I treat every one equally" or "I never differentiate between my patients based on social status or other factors." This reticence to acknowledge that differential care even exists actually prevents us from having open and honest discussions about what constitutes a fair distribution of rehabilitation services. Differential care starts on the macro level and trickles down to us as clinicians. In the absence of a universal single-payer system, health care throughout our country is always delivered on an unequal playing field. Some patients come to us without insurance, some have public aid or Medicare, and others are lucky enough to have excellent commercial policies without network restrictions, copayments, or strict utilization caps. The very privileged few have private resources to supplement their commercial policies and can pay privately for unlimited health care. On an institutional level, hospitals must decide how to operate within this environment riddled with inequities. Hospital operations are largely driven by their funding, mission, and business model. A county-run and funded institution created to provide safety net services to patients regardless of insurance status faces different challenges than a for-profit private hospital with obligations to its stockholders. But, regardless of mission, few hospitals publicize their policies regarding differential care. As a patient, I do not really know how my hospital determines which patients get admitted, how they make room assignments, or whether I am receiving the same services as my roommate. It is at this level that a more transparent and clearly defined set of policies that outlines what constitutes a minimally acceptable, safe package of services might be helpful, then we might be reassured that every patient within our hospital is receiving basic care even while acknowledging that some VIPs get extra perks. Policies about minimal standards would help in the institutional (or macro) realm, but differential care also exists on a micro level: at the bedside. It is at this level that I find even less scrutiny or discussion. As clinicians, we all have some control over how we spend our time and who gets our attention, and our attention and compassion may actually be a more critical factor than any other health care commodity. At the end of the day, when exhausted and ready to head home, I often have a moment when I decide whether to spend an extra 15 or 30 minutes checking on a patient. On an individual case-by-case basis, how do I decide who to see and why? I am not proud of the fact that my personal "policy" is rarely based on any external data or evidence about patient need. I often see the "squeaky wheel" because I know it will make my day less problematic tomorrow. I sometimes see the patient who provides me with the greatest satisfaction personally, the one who is most likely to appreciate my efforts or thank me for my concern. Sometimes my decision is embarrassingly random, and I will spend extra time with a patient who happens to cross my path in the hallway. Sometimes I see the VIP because I know it is important to my employer to provide outstanding care to these patients. But, as a social worker cognizant of society's biases, I often opt to see a patient or family member who I know is flying coach or taking the bus. I will spend my discretionary time (sometimes my personal time) checking on an abused child in state custody who lacks a parent advocate and has no visitors, or I will see a patient who has very limited health care resources and who is facing nursing home placement, or I will call a depressed patient who is struggling with social isolation in the community. This is also differential care of sorts and sometimes gets lost in discussions about rock stars and VIPs. Every day we make very personal decisions that clarify our own values and can either contribute to or counterbalance the inequities that exist in our communities.