Who should make medical decisions for children, when should a surgeon hang up their scalpel, and where do we draw the line between just culture and accountability?
When Should Children Make Their Own Medical Decisions?
Fourteen-year-old Max is caught in a tricky legal battle between his separated parents, but the stakes are much higher than which of them has custody over him. Rather than where and with whom he will live, which has already been decided, the questions are how he will live—and who will he be? Max was born female, and his parents disagree on whether he should receive sex reassignment therapy, primarily hormone suppression medication (i.e., “puberty blockers”) and testosterone to transition to a male body. Max’s mother, Sar- ah, his custodial parent, is fully supportive of what her son wants, particularly if it will ease his gender dysphoria; however, his father, Clark, is concerned that it is all happening too soon and too fast, and he doesn’t want his daughter to receive any irreversible treatment. Also caught in the middle of this dispute is British Columbia Children’s Hospital, which is ready to honor Max’s wishes and proceed with the treatment, believing that it is in his best interest and that he has the right to give his informed consent—only they can’t deliver treatments until both parents agree, or the courts rule in Max’s favor.
If this case were happening on American soil, where would the law and the medical community side? In general, the U.S. Constitution and most state laws strongly protect the rights of parents to make decisions for their children, with a clear mandate to serve the best in- terest of the child. As with Max in British Columbia, the trouble comes when parents can’t agree on what the child’s best interest is. In determining this, we can turn to the American Academy of Pediatrics (AAP), which has released comprehensive
guidance on caring for and supporting transgender children and adolescents, as well as the resources to do so.
Recognizing the serious mental health implications for those who identify as transgender, including depression, anxiety, self-harm, and suicidal ideation, the AAP emphasizes a gen- der-affirmative care model (GACM). GACM provides “developmentally appropriate care is oriented toward understanding and appreciating the youth’s gender experience,” and form- ing a “strong, nonjudgmental partnership with youth and their families.” Their recommen- dations for providers focus on respecting the gender with which the youth identifies and supporting the whole family to meet their emotional and mental health needs. They also urge providers to be properly educated regarding transgender needs and that pediatricians advocate for education and acceptance, and for policies and laws to protect transgender youth from discrimination and violence.
Behavioral Health — Warning Signs of Teen Suicide
Often, parents don’t recognize the warning signs of suicide in teenagers until it’s too late. But with the rising rates of teenage suicide in the United States and record numbers of calls and texts to suicide hotlines in the last few years from children 13–15 and younger, this is a problem that requires vigilance, sensitivity, and proactive intervention from teachers and parents alike. To aid in preventing suicidal thoughts, Nikki Kontz, a clinical director at Teen Lifeline in Arizona, recommends that parents teach their children prob- lem solving and coping skills at a young age and reassuring and encouraging children to feel comfortable talking to them about anything—and model good behavior in coping with problems and on social media.
It’s also important to recognize that teenagers may exhibit warning signs that are different from adults. For example, depression may manifest in teens as irritability or anger rather than sadness. They may complain about aches and pains that seem to have no physical cause, and they may be particularly sen- sitive to criticism and failure. While teens may socialize less or distance them- selves from their parents, they are less likely to isolate themselves as adults do and may maintain some friendships or form new ones.
If you are thinking about suicide or are worried about a friend or loved one, talk to someone now. The national Lifeline network is available 24/7.
Long-Term Care — CMS Calls Out Nursing Homes
A study published in Health Affairs in November 2018 found that Nursing Home Compare (NHC) data, a standard measure of quality at skilled nursing facilities (SNFs) and nursing homes, does not paint an accurate picture of patient safety—most notably in capturing patient safety standards such as pressure injuries, infections, falls, and medication errors. In response to the criticism,
the Centers for Medicare & Medicaid Services (CMS) is looking to overhaul the way rankings are derived by incorporating a composite measure of healthcare-acquired infections to hold facilities accountable for their pa- tient safety performance. According to Dr. Kate Goodrich, CMS’ chief medical officer, the agency also will “continue to explore additional facets of and mea- sures associated with safety in nursing homes going forward.”
Surgery — When is a Surgeon Too Old to Operate?
It’s a far cry from Logan’s Run, but as some hospitals—including Temple University Hospital and University of Pittsburgh Medical Center—implement mandatory screening of older surgeons to gauge the state of their skills and faculties, unsurprisingly many surgeons are speaking out against the proposal.
Dr. Herbert Dardik, chief of Vascular Surgery at Englewood Hospital and Medical Center in New Jersey, was one of those who initially resented the idea. After he nodded off in the OR while observing a procedure, the then-80-year-old surgeon’s performance came under scrutiny. But then he found himself ques- tioning an older pilot’s fitness for flying and realized there might be some- thing to people’s concerns, so he volunteered to be the first doctor evaluated by the Aging Surgeon Program at Sinai Hospital in Baltimore, Maryland. Now in its fifth year, the program has screened only eight surgeons, age 55–81. Dr. Dardik received a favorable evaluation, but when he began experiencing back pain in 2016, he voluntarily gave up surgery and now, at age 83, focus- es on research and teaching. Though he supports a late-career practitioner program, and in fact the American College of Surgeons has recommended voluntary physical, visual, and neurocognitive testing for older surgeons, oth- ers—including his colleagues—are not so easily convinced. Research shows that surgeons are not the most objective when it comes to their own health, competence, and retirement. But a mandatory retirement age also opens the door to age discrimination and potentially removes competent doctors from practice prematurely.
While the debate rages on between healthcare researchers, analysts, and care providers, the physician work force continues to age; a quarter of practicing physicians were 65 or older in 2015, and more than 122,000 of them contin- ued to care for patients in 2017. To address these concerns and fuel the dis- cussion, the Society of Surgical Chairs is soon publishing a new white paper, “Transitioning the Senior Surgeon.”
Outpatient Surgery Caps
When it comes to patient safety in the operating room, it’s all in the name — and where it’s written. As teams constantly change and staff moves around, it’s important to know whom you’re working with and what they do. Names are typically written on white boards and are prominently displayed on name badges, but these prove to be insufficient or invisible in an OR (aka an “oper- ating theater”).
Dr. Rob Hackett, an anesthetist based in Australia, found a solution: He wrote his name on his scrub cap. That simple act began a movement that has been sweeping the nation—as well as attracting a share of ridicule and controversy over the value of the unorthodox practice. Popularized over the last year with the hashtag
#TheatreCapChallenge, proposed by student midwife Alison Brin- dle, the idea is to make everyone’s name and role clearly visible—right on their surgical cap—to eliminate confusion in chaotic situations, improve teamwork and communication, and avoid staff misidentification, which can contribute to medical errors. All it takes to label your cap is a Sharpie and some tape, but rather than continue using disposable caps,
some hospitals have embraced a more permanent solution, including Stanford Health Care in California, which has been upgrading to embroidered, reusable cloth caps—and is seeing an immediate, positive outcome on patient care and safety.
Diagnostic Excellence — A Shocking Misdiagnosis
As a high school senior, Courtney began suffering from flu-like symptoms that never went away: fever, fatigue, dizziness, sore throats. She figured she had mononucleosis, but when doctors were unable to find a physical cause, they diagnosed her with depression and prescribed Prozac, but the medication didn’t help — because Courtney wasn’t depressed. Nonetheless, without any other explanation, Courtney’s condition worsened enough for her to agree an extreme solution, electroconvulsive therapy (ECT).
Nine sessions later, she had a swiss-cheese memory, was losing her sense of self—and still her symptoms persisted. Finally a psychiatrist tested her again, and they arrived at a new diagnosis: myalgic encephalomyelitis, for- merly known as chronic fatigue syndrome (ME/CFS), a condition similar to Epstein-Barr virus, a common virus that can cause mono. Although ME/CFC affects 30 million people around the world, it has commonly been dismissed by doctors as “exhaustion,” and it affects four times as many women than men. Women, especially women of color, are also more likely to be disbelieved about their health and symptoms than men, with their symptoms attributed to “female hysteria” and depression; in fact, studies in the 1990s showed that 30–50% of women were
misdiagnosed with depression. Thus, the deck was stacked against Courtney, and she believes this inherent gender bias led to her misdiagnosis and the loss of six years of her life.
Infection Prevention — Auditing Catheter Dislodgements
A survey of 1,500 clinicians published in the December 2018 issue of the
Journal of the Association for Vascular Access indicates that accidental dis- lodgement of vascular access devices, most commonly peripheral intravenous catheters, is prevalent, underreported, and problematic—beyond the impact it has on central line associated blood stream infections. The survey shows that 68% of clinicians estimate dislodgement occurs frequently, often daily or even several times a day, due to events such securement and dressing failures, con- fused patients, and patients removing catheters. This adds up to a lot of wast- ed dollars for healthcare systems and patients, as much as $1 billion a year. The survey’s author,
Nancy Morneau, RN, PhD, emphasizes the importance of auditing and documenting these incidents via the electronic medical record in order to help increase education, identify where there are safety issues, and develop solutions.
Medication Safety — Just Culture vs. Individual Accountability
In December 2017, a Tennessee nurse intended to give a patient a routine sedative (midazolam) but instead injected vecuronium, a neuromus- cular-blocking (NMB), or paralyzing, agent that is used to keep patients still during surgery and is part of the cocktail used to execute inmates on death row in some states. The patient was then put into a body-scanning machine and left alone to be scanned for as long as 30 minutes before staff realized the patient was not breathing and that a medication error had been made. Medical staff began CPR, according to a CMS investigation report; however, by the next day, the patient’s neurological sequelae had worsened, and the patient died after life support was withdrawn.
The medical error occurred when the nurse was asked to administer Versed, the brand name for midazolam. When she could not find it on the list from an automated dispensing cabinet (ADC), she initiated an override that unlocks all medications in the ADC, not just those prescribed for the patient. She entered “VE” again into a search field, and selected the first medication that populated the results: the NMB agent vecuronium, not Versed. The nurse has since been charged with reckless homicide, prompting an uneasy debate over whether liability for the patient’s death ultimately lies with the hospital, which enabled the nurse to override the ADC and administer the wrong medication, or with the nurse for the act itself. Straddling the line between just culture and individ- ual accountability, there is no clear answer to this question, but the Institute for Safe Medication Practices (ISMP) points to the case as a reminder that these errors can happen anywhere, and there are best practices and policies that can be implemented to mitigate risks.
The Authority has previously written about the dangers of paralyzing agents like vecuronium, as well as the use of overrides. Some strategies to avoid dev- astating results include restricting storage of paralyzing agents in care areas where patients are properly ventilated and monitored, and developing clearly stated organizational policies and criteria for ADC system overrides that lim- it access to medications until orders have been reviewed and approved by a pharmacist.
Media Watch — Patient Safety Documentary
To Err Is Human: A Patient Safety Documentary (2018) is now available to purchase on VOD, DVD, and Blu-Ray. Directed by Mike Eisenberg, son of pa- tient safety pioneer Dr. John M. Eisenberg, this film explores the silent epidem- ic of medical mistakes and those working to address it and showcases simple solutions that can improve the quality of healthcare. Visit
www.toerrishuman- film.com for more details and a list of upcoming screenings around the United States, including an event at Penn State Health Milton S. Hershey Medical Cen- ter in Hershey, Pa., on March 15, 2019, during Patient Safety Awareness Week.
PSA News
Ligature Risk Communique 2.0
The Authority has just published
an update on ligature risks which includes information on National Patient Safety Goal 15.01.01 revisions effective July 1, 2019; Ligature Risk Gap Analysis data from facilities; and the latest CMS recommendations on monitoring psychiatric patients requiring medical care in a nonpsyschiatric setting.
Visit the
PSA website for more information on ligature risks and other behav- ioral health resources.
