During the hearing last Thursday between Anne Woodlen and Iroquois Nursing Home there was a telling moment when Peter Sinatra was being cross-examined by the Iroquois lawyer. Peter, as he officially said for the record, is a nurse practitioner in the Palliative Care Medical Unit of Crouse Hospital. He’s been working at Crouse for about thirty years and if you want an image of him, just think “Pete Seeger”—same beard, some guitar playing, and a “study war no more” philosophy.
So there we are in the boardroom lined up across from the judge, and the Iroquois lawyer—Janet somebody from Hancock—is on my left and Peter is on my right. Peter has testified to useful stuff such as lab work showing the extent and worsening of my kidney disease, likewise my hyperglycemia and some other medical stuff. Keep in mind here that the Iroquois did not bring to the table a doctor or any serious medical stuff. What they brought was two lawyers and a nursing supervisor who basically said that she’d seen me get out of a wheelchair and get into a car and, therefore, I was good to live independently, do the cooking and the laundry.
Now Janet is sort of leaning across me to cross-examine Peter, and it goes kind of like this:
• How many times a week do you see Anne? (Three to four days)
• How much time do you spend with Anne? (Five to 45 minutes)
• Are you part of a team?
• What time do you punch out?
• How many patients are in your case load?
Peter’s reply to the last question was “seven to nine,” and the Iroquois’ response was a gasped “That’s all?” To all of the other questions, Peter’s answers had a certain “huh, what’re you talking about” quality and I SO wanted to jump in and explain the Iroquois and Crouse to each other, and now I will.
The Iroquois has a top-down approach to the care of its residents. First, they built a hierarchal administrative structure made of steel and welded into place. Then they staffed the hierarchy with job titles—administrator, director of social services, director of discharge planning, director of nursing, and so forth. Then the directors hired staff members, assigned them to teams and scheduled regular meetings of all the teams whether they had anything to talk about or not. Then they started bringing in sick people, putting them on the conveyor belt and processing them through the same departments whether they needed to be or not.
Crouse Hospital starts by sending someone—often a nurse practitioner (NP)—into the room and asking the patient what s/he needs. They talk. When they both think they have a pretty good grip on the situation then the NP goes out and calls up specific other people (doctors, physical therapists, social workers, etc.), as indicated by the interview, and then the other people come see the patient. They, too, talk. Then some of the other people do stuff to the patient; some of the people call other people; some of the people say, “Nah, I got nothing to offer here,” and are never seen again.
Crouse, from the patient’s point of view, doesn’t have “teams” in the sense that the Iroquois has “teams.” At Crouse, people treat the patient, then talk to other people who are treating the patient when they run into them somewhere, or call them up. Crouse treats the person; the Iroquois processes the subject. There is virtually no individualization of care at the Iroquois, whereas virtually all the care at Crouse is individualized. At Crouse if you need seltzer water then you get seltzer water; at the Iroquois if you want seltzer water then you get told they don’t have it.
At the Iroquois, if you need assistance to the bathroom then you are told to wait because there is only one specific staff member designated for you and that job, and she is late coming to work. At Crouse, if you need assistance to the bathroom then you will get it from the first available staff member, i.e., from any one of the nurses or nursing assistants working on your unit. Crouse is about taking care of the patient; the Iroquois is about taking care of the staff.
Asking Peter when he punches out is silly because he punches out exactly when all the most important work is finished. He’s not going home and leave a patient in crisis. At the Iroquois, I could not have a staff member accompany me out to a physician’s appointment because it would cross the line between first shift and second shift and heaven forefend that a staff member should fail to punch out on time.
The Iroquois basically treats their residents as mechanical products to be kept functioning, not as people to be cared for. Keep in mind here that the Iroquois has a 40-bed unit designated as “palliative care” and Peter works on the Palliative Care Medical Unit. They are working with exactly the same patients. According to my understanding of Crouse and the Iroquois, people like Peter listen to the patient, figure out the best possible care plan, and then transfer the patient to the Iroquois where the care plan is executed without it ever being re-evaluated or modified.
And you know why? Because the most important part of Crouse’s care comes from the staff listening to the patient. It all begins and ends with the patient, not the staff team meeting. Crouse hires staff who actually like people. The Iroquois never listens to the patient because they have no concept that the patient is a person. The Iroquois hires staff who are foreign-born and cannot understand “Please close the window.” Peter and I talk about life, ice cream, oxycodone and death (i.e., the cessation of eating ice cream); Iroquois staff check off boxes when tasks are completed without ever talking to the resident.
Isn’t the “task” of palliative care to help a person die with comfort? How do you put that in a check-box? Dying with comfort is all about being wrapped in a cashmere blanket, not locked into a straightjacket. Peter and the Iroquois lawyer had absolutely no context in which to be able to understand each other.