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December 2019Volume 23p8No. 12FUTURE HOSPITALISTDiversity of trainingin hospital medicinep10KEY CLINICAL QUESTIONImproving inpatient painmanagementp16IN THE LITERATUREComplications afternoncardiac surgeryExperts bringclarity toend-of-lifedifficultiesUnderstanding family perspectiveis an important factorBy Thomas R. CollinsACHANGE SERVICE REQUESTEDPresorted StandardU.S. PostagePAIDPermit No. 384Lebanon Jct. KY01 6 7THN19 12.indd 1Courtesy Lloyd’s Studio Photography, Boca Raton, Fla.the-hospitalist.orgContinued on page 6Dr. Elizabeth GundersenTHE HOSPITALISTP.O. Box 3000,Denville, NJ 07834-3000 Vietnam veteran steered clear of thehealth care system for years, thenshowed up at the hospital with pneumonia and respiratory failure. He waswhisked to the intensive care unit, and cancerousmasses were found.The situation – as described by Jeffrey Frank,MD, director of quality and performance at Vituity, a physician group in Emeryville, Calif. – thengot worse.“No one was there for him,” Dr. Frank said. “He’slaying in the ICU; he does not have the capacityto make decisions, let alone communicate. So thecare team needs guidance.”Too often, hospitalists find themselves in confusing situations involving patients near theend of their lives, having to determine how to goabout treating a patient or withholding treatment when patients are not in a position to announce their wishes. When family is present, thehealth care team thinks the most sensible courseof treatment is at odds with what the familywants to be done.At the Society of Hospital Medicine 2019 AnnualConference, hospitalists with palliative care training offered advice on how to go about handlingthese difficult situations, which can sometimesbecome more manageable with certain strategies.For situations in which there is no designatedrepresentative to speak for a patient who is unresponsive – the so-called “unbefriended patient” orSURVEY INSIGHTSLEADERSHIPTresa Muir McNeal,MD, FACP, SFHMLeslie Flores,MHA, SFHMp3Unit-based rounding inthe real world: Balance andflexibility are essentialEnvisioning the futurep27 of hospital medicine:Existential crisis at hand11/19/19 1:36 PM

FROM THE SOCIETYDecember 2019Volume 23The QI pipelinesupported by SHMStudent Scholar GrantsBy Emily Gottenborg, MD, andAshley Duckett, MD, FHMAs fall arrives, new internsare rapidly gaining clinical confidence, and residency recruitment seasonis ramping up. It’s also time toannounce the opening of the Society of Hospital Medicine’s StudentHospitalist Scholar Grant Programapplications. We are now recruiting our sixth group of scholars forboth the Summer and LongitudinalPrograms.Since its creation in 2015, the granthas supported 23 students in this incredible opportunity to allow trainees to engage in scholarly work withguidance from a mentor to betterunderstand the practice of hospitalmedicine and to further grow ourrobust pipeline.The 2018-2019 cohort of scholars,Matthew Fallon, Philip Huang, andErin Rainosek, have just recentlyconcluded their projects and arecurrently preparing their abstractsfor submission for Hospital Medicine 2020, where there is a track forEarly-Career Hospitalists.The projects targeted a diverseset of domains, including improvingupon the patient experience, readmission quality metrics, geographiccohorting, and clinical documentation integrity – all highly relevanttopics for a practicing hospitalist.Matthew Fallon collaborated withhis mentor, Venkata Andukuri, MD,at Creighton University School ofMedicine in Omaha, Neb., to reducethe rate of hospital readmissionfor patients with heart failure, byanalyzing retrospective data in aroot-cause analysis to identify factors that influence readmission rate,then targeting those directly. Theyalso integrated the patient experience by seeking out patient inputas to the challenges they face in themanagement of their heart failure.Philip Huang worked with hismentor, Ethan Kuperman, MD, atthe Carver College of Medicine,University of Iowa, to improve geographic localization for hospitalizedpatients to improve care efficiency.They worked closely with an industrial engineering team to create aworkflow model integrated into theCOORDINATING EDITORSDennis Chang, MDTHE FUTURE HOSPITALISTJonathan Pell, MDKEY CLINICAL GUIDELINESCONTRIBUTING WRITERSMoises Auron, MD, SFHM; Suzanne Bopp;Kathryn Brouillette, MDCM; Dennis Chang,MD, FHM; Steve Cimino;Thomas R. Collins; Ashley Duckett, MD,FHM; Nicholas Dupuis, DO; Leslie Flores,MHA, SFHM; Lesley B. Gordon, MD, MS;Emily Gottenborg, MD; Alan M. Hall, MD;Elizabeth Herrle, MD; Sarah Horman, MD;Erin King, MD, FAAP; Brian Kwan, MD,FHM; Tresa Muir McNeal, MD, FACP,SFHM; Christopher Moriates, MD, SFHM;Bianca Nogrady; Sarah Richards, MD;Pallabi Sanyal-Dey, MD; Patricia Seymour,MD, MS, FAAFP, FHM; Jennifer Smith;Kerry Dooley Young; Emily Zarookian, MD;Mitchel L. Zolerhospital EHR to designate patientlocation and were able to better understand the role that other professions play in improving the healthcare delivery.Finally, Erin Rainosek teamed upwith her mentor, Luci Leykum, MD,at the University of Texas HealthScience Center at San Antonio, toapply a design thinking strategy toredesign the health care experiencefor hospitalized patients. She engaged in over 120 hours of patientinterviews and ultimately identifiedkey themes that impact the experience of care, which will serve astarget areas moving forward.The student scholars in this cohort gained significant insight intothe patient experience and qualityissues relevant to the field of hospital medicine. We are proud of theiraccomplishments and look forwardto their future successes and careersin hospital medicine.If you would like to learn moreabout the experience of our scholarsthis past summer, they have postedfull write-ups on the Future Hospitalist RoundUp blog in HMX, SHM’sonline community.For students interested in becoming scholars, SHM offers twooptions to eligible medical students– the Summer Program and theLongitudinal Program. Both programs allow students to participatein projects related to quality improvement, patient safety, clinicalresearch, or hospital operations, inorder to learn more about careerpaths in hospital medicine. Students will have the opportunityto conduct scholarly work with amentor in these domains, with theoption of participating over thesummer during a 6- to 10-week period or longitudinally throughout thecourse of a year.Discover additional benefits andhow to apply on the SHM website.Applications will close in late January 2020.FRONTLINE MEDICALCOMMUNICATIONS EDITORIAL STAFFExecutive Editors Denise Fulton,Kathy ScarbeckEditor Richard PizziCreative Director Louise A. KoenigDirector, Production/ManufacturingRebecca SlebodnikEDITORIAL ADVISORY BOARDGeeta Arora, MD; Michael J. Beck, MD;Harry Cho, MD; Marina S. Farah, MD,MHA; Stella Fitzgibbons, MD, FACP, FHM;Benjamin Frizner, MD, FHM;Nicolas Houghton, DNP, RN, ACNP-BC;James Kim, MD; Melody Msiska, MD;Venkataraman Palabindala, MD, SFHM;Raj Sehgal, MD, FHM; Rehaan Shaffie, MD;Kranthi Sitammagari, MD;Amith Skandhan, MD, FHM;Lonika Sood, MD, FACP, FHM;Amanda T. Trask, FACHE, MBA, MHA,SFHM; Amit Vashist, MD, FACP;Jill Waldman, MD, SFHMTHE HOSPITALIST is the official newspaper of theSociety of Hospital Medicine, reporting on issuesand trends in hospital medicine. THE HOSPITALISTreaches more than 35,000 hospitalists, physicianassistants, nurse practitioners, medical residents, andhealth care administrators interested in the practiceand business of hospital medicine. Content forTHE HOSPITALIST is provided by Frontline MedicalCommunications. Content for the Society Pages isprovided by the Society of Hospital Medicine.Copyright 2019 Society of Hospital Medicine. Allrights reserved. No part of this publication may bereproduced, stored, or transmitted in any form or byany means and without the prior permission in writingfrom the copyright holder. The ideas and opinionsexpressed in The Hospitalist do not necessarilyreflect those of the Society or the Publisher. TheSociety of Hospital Medicine and Frontline MedicalCommunications will not assume responsibility fordamages, loss, or claims of any kind arising fromor related to the information contained in thispublication, including any claims related to theproducts, drugs, or services mentioned herein.Letters to the Editor: [email protected] Society of Hospital Medicine’s headquartersis located at 1500 Spring Garden, Suite 501,Philadelphia, PA 19130.Dr. Gottenborg is director of theHospitalist Training Program withinthe Internal Medicine ResidencyProgram at the University ofColorado. Dr. Duckett is assistantprofessor of medicine at the MedicalUniversity of South Carolina.December 201902 3 4THN19 12.indd 2PHYSICIAN EDITORDanielle B. Scheurer, MD, SFHM, MSCR;[email protected] EDITORAnika Kumar, MD, [email protected] Offices: 2275 Research Blvd, Suite 400,Rockville, MD 20850, 240-221-2400, fax 240-221-2548No. 12THE SOCIETY OF HOSPITAL MEDICINEPhone: 800-843-3360Fax: 267-702-2690Website: www.HospitalMedicine.orgLaurence Wellikson, MD, MHM, CEOVice President of Marketing &CommunicationsLisa [email protected] Communications ManagerBrett [email protected] Communications SpecialistCaitlin [email protected] BOARD OF DIRECTORSPresidentChristopher Frost, MD, SFHMPresident-ElectDanielle Scheurer, MD, MSCR, SFHMTreasurerTracy Cardin, ACNP-BC, SFHMSecretaryRachel Thompson, MD, MPH, SFHMImmediate Past PresidentNasim Afsar, MD, MBA, SFHMBoard of DirectorsSteven B. Deitelzweig, MD, MMM, SFHMBryce Gartland, MD, FHMFlora Kisuule, MD, MPH, SFHMKris Rehm, MD, SFHMMark W. Shen, MD, SFHMJerome C. Siy, MD, SFHMChad T. Whelan, MD, MHSA, FHMFRONTLINE MEDICALCOMMUNICATIONS ADVERTISING STAFFVP/Group Publisher; Director,FMC Society PartnersMark BrancaNational Account ManagersValerie Bednarz, 973-206-8954cell 973-907-0230 [email protected] Krivopal, 973-206-8218cell 973-202-5402 [email protected] Sales RepresentativeHeather Gonroski, [email protected] Wilson, [email protected] Director of Classified SalesTim LaPella, 484-921-5001cell 610-506-3474 [email protected] Offices 7 Century Drive,Suite 302, Parsippany, NJ 07054-4609973-206-3434, fax 973-206-9378THE HOSPITALIST (ISSN 1553-085X) is publishedmonthly for the Society of Hospital Medicine byFrontline Medical Communications Inc., 7 CenturyDrive, Suite 302, Parsippany, NJ 07054-4609. Printsubscriptions are free for Society of Hospital Medicine members. Annual paid subscriptions are available to all others for the following rates:Individual: Domestic – 184 (One Year), 343 (Two Years), 495 (Three Years),Canada/Mexico – 271 (One Year), 489 (Two Years), 753 (Three Years), Other Nations-Surface – 335(One Year), 646 (Two Years), 946 (Three Years),Other Nations - Air – 431 (One Year), 835 (Two Years), 1,264 (Three Years)Institution: United States – 382;Canada/Mexico – 463 All Other Nations – 537Student/Resident: 51Single Issue: Current – 35 (US), 47 (Canada/Mexico), 59 (All Other Nations) Back Issue – 47(US), 59 (Canada/Mexico), 71 (All Other Nations)POSTMASTER: Send changes of address (with oldmailing label) to THE HOSPITALIST, SubscriptionServices, P.O. 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ANALYSISUnit-based rounding in the real worldBalance and flexibility are essentialBy Tresa Muir McNeal, MD,FACP, SFHMMany hospitalists agreethat their most productive and also sometimesleast productive workcan happen in the setting of interdisciplinary rounds. How can thisparadox be true?Most hospitals strive to assemblethe health care team every day fora brief discussion of each patient’sneeds as well as barriers to a safe/successful discharge. On most floorsthis requires a well-choreographed“dance” of nurses, case managers,social workers, physicians, and advanced practice providers comingtogether at agreed-upon times. Allteam members commit to efficientsynchronized swimming throughthe most high-yield details for eachpatient in order to benefit the patients and families being served.Of course, there are always challenges to this process in the unpredictable world of patients withacute needs. One variable that isat least partially controllable andtends to promote a more cohesiveinterdisciplinary experience is thatof hospitalist unit-based rounding.The 2018 State of Hospital Medicine (SoHM) survey reveals that 68%of hospital medicine groups servingadults with greater than 30 physicians employ some degree of unitbased rounding; this trend decreaseswith smaller group size. About54% of academic hospital medicinegroups use some amount of unitbased rounding. Not surprisingly,smaller hospital medicine groupsare less likely to have this routine,likely because they cover fewer totalnursing units.One of the most obvious benefits to unit-based rounding is thatthe physician or advanced practiceprovider is more reliably able to participate in the interdisciplinary discussions that day. When more of theteam members are at the table eachday, patients and families have thebest chance of hearing a consistentmessage around the treatment anddischarge plans.There are challenges to unit-basedrounding as well. If patients transferto different floors for any variety ofreasons, strict unit-based roundingmay increase handoffs in care. Ifa hospital has times when it isn’tcompletely full and nursing unitshave a varying percentage of beingoccupied, strict unit-based roundingcan cause significant workload inequities among physicians on differentunits, depending on numbers of patients on each unit.If there is no attempt at unitbased rounding in larger hospitals,some physicians may be runningamong five or more units. Theywork to find different care manag-ers, nurses, and pharmacists – not tomention the challenges of catchingpatients in their rooms betweentheir departures for diagnostic studies and procedures.It is often good to balance the benefit of promoting unit-based roundswith the reality of everyday patientcare. Some groups maintain thatthe physician/patient relationshiptrumps the idea of perfect unit-basedrounding. In other words, if a physician establishes a relationship with apatient while they are in the ED being admitted or boarding from overnight, that physician will continueseeing the patient regardless of thepatient being assigned to a differentunit. It can help for groups to agreethat the pursuit of unit-based rounding may create some inequity in thenumbers of patients seen each daybecause of these issues.In a larger hospital, certain unitsare often dedicated to specialtycare. While most hospitalists wantto maintain general medical knowledge, there are some who may enjoyhaving portions of their practicedevoted to perioperative medicineor cardiac care, for instance. Thispromotes familiarity among hospitalists and groups of consultantphysicians and nurse practitioners/physician assistants. Over timethis allows for enhanced teamworkamong those physicians, the nursingteam, and the specialty physicians.Depending on the group’s schedule, patients can be reassigned coinciding with the primary change ofDr. McNeal is the division directorof inpatient medicine at BaylorScott & White Medical Center inTemple, Tex.service day. This resets the physicians’ patients in the most idealunit-based way on the evening priorto the first day of rounding for thatweek or group of shifts.No matter how you do it, the goalof unit-based rounding is time efficiency for the care team and carecoordination benefits for patientsand families. If you have other suggestions or questions, go online toSHM HMX to join the discussion.Take-home message: Unit-basedrounding likely has its benefits.Don’t let the inability to achieveperfection in patient distributionto the physicians each day lead toabandonment of attempting theseprocesses.Choosing Wisely and its impact on low-value careFocus energy on ‘low-hanging fruit’By Moises Auron, MD, SFHMIt is a well-known fact that health care expenditure in the United States occupies a largeproportion of its gross domestic product. Infact, it was 17.8% in 2016, almost twice what isexpended in other advanced countries. However,this expenditure does not necessarily translateinto optimal patient outcomes.In 2012, the Institute of Medicine reported thatthe U.S. health care system wastes 750 billionper year in spending that does not provide anymeaningful outcome to patients or the system;and patients can also suffer a financial impactfrom the delivery of low-value care.In 2013, the Pediatrics Committee of the Societyof Hospital Medicine published five recommen-dations through the Choosing Wisely campaignaimed to decrease the use of low-value interventions. These recommendations were:1. Do not order chest radiographs (CXR) in children with asthma or bronchiolitis.2. Do not use systemic corticosteroids in children aged under 2 years with a lower respiratory tract infection.3. Do not use bronchodilators in children withbronchiolitis.4. Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy.5. Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.This publication led to the implementation ofquality improvement initiatives across differentthe-hospitalist.org02 3 4THN19 12.indd 3 3hospitals and institutions nationally. Eventually,a team of hospitalists developed a report cardthat could help measure the utilization of theseinterventions in hospitals that were part of theChildren’s Hospital Association (CHA). The datastemming from the report card analysis wouldallow for benchmarking and comparing performance, as well as determining the secular trendin utilization of these procedures across the different institutions of the CHA.Reyes et al. recently published the impact ofutilization of these scorecards among all hospitalmembers of the CHA in the Journal of HospitalMedicine, noting a positive impact of the SHMChoosing Wisely recommendation in decreasingthe utilization of low-value interventions. TheContinued on following pageDecember 201911/19/19 12:10 PM

ANALYSISHave lower readmission rates led to highermortality for patients with COPD?By Christopher Moriates, MD,SFHMThere is at least one aspect of“Obamacare” that my mother-in-law and I can agreeon: Hospitals should not getpaid for frequent readmissions.The Hospital Readmission Reduction Program (HRRP), enacted bythe Centers for Medicare & MedicaidServices in 2012 with the goal of penalizing hospitals for excessive readmissions, has great face validity andnoble intentions. Does it also have apotentially disastrous downside?The HRRP has been a remarkable success. It moved the nationalneedle significantly on readmissionrates. There are some caveats aboutincreases in observation status patients and other shifts that couldaccount for some of the difference,but it is fairly uncontroversial that,overall, there are fewer 30-dayreadmissions across the countryfollowing initiation of HRRP. That isencouraging evidence of the positiveimpact that policy can make to drivechanges for specific targets.However, there is also a more controversial side. A number of studieshave suggested reductions in readmission rates may have been associated with an increase in mortality insome patient groups. You dischargea patient and hope they won’t reContinued from previous pageauthors compared the performance before andafter the publication of the recommendations fora 9-year period (2008-2017). The most relevant impact occurred in children with bronchiolitis, witha decrease of 36% of bronchodilator use and of31% in CXR utilization. In children with asthma,CXR utilization decreased by 20.8%. The authorsfound that, although there was a steady decreasein the utilization of low-value services, this wasstill limited.What factors could impact the effectivenessof high-value quality initiatives? First of all,quality improvement requires a substantialinvestment of collective effort and time. Itrequires a change in culture that often involves changing longstanding paradigms. TheChoosing Wisely recommendations targeta very specific, low-clinical-severity population – the focus is on “uncomplicated” disease.This is important as you don’t want to pursueaggressive unnecessary intervention in children and potentially cause harm – for example,unnecessary use of steroids in a child withuncomplicated bronchiolitis who may improvewith nasal suctioning alone. There is a need toappraise patients with more complex presentation of these diseases (for example, patientsthat require escalation of care to ICU), andthis is beyond the scope of Choosing Wisely .Further research is needed to see if higher-value care interventions can beimplemented among thesehigher acuity and severitypatients.In our institution, we havecreated specific care paths thatfacilitate following these recommendations. Essentially, wehave leveraged the EHR ordersets to avoid the inclusion ofDr. Auronlow-value interventions; allstakeholders (respiratory therapy, nursing, etc.)are aware of the care path and ensure compliance.Even further, as a consequence of the change inculture toward high-value care, we have identifiedlow-value interventions in settings where high-value quality improvement can be implemented – forexample, we found that at least 20% of noncritically ill children undergoing an appendectomy re-December 201902 3 4THN19 12.indd 4The researchers seem to havefound some important insights: The all-cause 30-day risk-standardized readmission rate declinedfrom 2010 to 2017. The all-cause 30-day risk-standardized mortality rate increasedfrom 2010 to 2017, and the rate ofincrease in mortality appears to beaccelerating. Hospitals with higher readmissionrates prior to COPD readmissionpenalties had a lower rate of increase in mortalities. Hospitals that had a larger decrease in readmission rates had alarger rate of increase in mortality.These researchers could notevaluate data at the patient leveland could not adjust for changes indisease severity. However, taken together, these findings suggest something bad may be happening here.The authors note that the associations with increased mortalityhave largely been seen in patientswith heart failure – and now COPD– which are chronic diseases characterized by exacerbations, as opposedto acute MI and pneumonia, whichare episodic and treatable. Perhapsin those types of disease, efforts toavoid readmissions may be moreuniversally helpful. Maybe.I find it concerning that there is“biological plausibility” for this association. Hospitalists know exactlyturn to the hospital, but perhapsyou should be more careful whatyou actually wish for.Overall, the evidence of an association between readmissionsand mortality has been conflicting. Headlineshave alternatelyraised alarmabout increaseddeaths and thenreassured thatthere has beenno change orperhaps evensome concordantDr. Moriatesimprovementsin mortality. Not necessarily surprising: These studies are all ofobservational design and use different criteria, datasets, and analyticmodels, which drive their seeminglyconflicting results.An article published recently inthe Journal of Hospital Medicineexamined the potential associationbetween changes in rates of chronic obstructive pulmonary disease(COPD) readmissions and 30-daymortality following HRRP introduction. While the initial HRRPprogram and subsequent analysesincluded patients with heart failure, acute MI, and pneumonia, theprogram was extended in 2014 to include patients with COPD. So, whathappened in this patient group? 4how this might have happened.Have you heard of pop-up alertsthat fire in the ED to let physiciansknow that this patient was discharged within the past 30 days?That alert is not meant to tell youwhat to do, but you might want toconsider trying to discharge themor place them in observation – useyour clinical judgment, if you knowwhat I mean.Within the past decade, observation units quickly cropped up allover the country, often not staffedby hospitalists nor cardiologists,where patients with decompensated heart failure, chest pain, and/or COPD, can be given Lasix and/ornebulizer treatments – at least justenough to let them walk back outthat door without an admission.As Ashish Jha, MD, wrote in 2018,“Right now, a high-readmission,low-mortality hospital will be penalized at 6-10 times the rate of alow-readmission, high-mortalityhospital. The signal from policymakers is clear – readmissions matter a lot more than mortality – andthis signal needs to stop.”Dr. Moriates is the assistant deanfor health care value at Dell MedicalSchool at the University of Texas,Austin. This article first appeared onthe Hospital Leader, SHM’s officialblog, at hospitalleader.org.ceive unnecessary antacid prophylaxis treatment.Changes always start small; quality improvement requires a lot of effort, and we must focusour energy on “low-hanging fruit,” and also begintackling higher complexity tasks. In the ChoosingWisely manuscript cited above, the authors foundthat there was a change in performance with atendency toward higher-value care, yet the changewas not as substantial as originally thought.How can we tackle higher complexity tasks if wefind it difficult to implement solutions for those oflower complexity? My answer is simple. Maintaina consistent and continuous focus on high value,and ensure the message is iterative and redundantwith feedback on performance, decrease in costs,and enhanced patient outcomes.Dr. Auron is the quality improvement and patientsafety officer in the department of hospitalmedicine at the Cleveland Clinic. He also servesas associate professor of medicine and pediatricsin the staff department of hospital medicine anddepartment of pediatric hospital medicine. Thisarticle first appeared on the Hospital Leader, SHM’sofficial blog, at hospitalleader.org.The Hospitalist11/19/19 12:13 PM

Post-IntensiveCare DemandsIntensive Caring.Some patients who spend three or moredays in an intensive or critical care unitneed extended recovery time in an acute-levelsetting before transitioning home.These post-intensive care patients can benefit fromspecialized care provided by clinicians with expertisein treating critically ill and medically complex patients.Our interdisciplinary care features daily physicianoversight, ICU/CCU-level staffing and specially trainedcaregivers that seek to improve outcomes and reduce costlyreadmissions for difficult-to-treat patients.For a clinical assessment of your medically complex patients needing prolonged acute-level care,visit kindredhospitals.com to find our hospital nearest you.Dedicated to Hope,Healing and RecoveryDaily Physician Oversight ICU/CCU-Level Staffing Reduced Readmissions 2019 Kindred Healthcare, LLC CSR 197883-04, EOE197883-04 HD Media Print Ad The Hospitalist Ad.indd 105 HOSP.indd 18/15/19 10:56 AM11/13/2019 12:48:15 PM

Palliative carehee!“unrepresented patient” – any sourceof information can be valuable. Andhealth care providers should seekout this input, Dr. Frank said.“When there is a visitor at the bedside, and as long as they know theperson, and they can start giving themedical providers some informationabout what the patient would havewanted, most of us will talk withthat person and that’s actually agood habit,” he said.Thirty-nine states and the Districtof Columbia have regulations onwhom health care providers shouldtalk to when there is no obvious representative, Dr. Frank said, notingthat most of these regulations follow a classic family-tree order. Butin the discouraging results of manysurveys of health care providers onthe subject, most clinicians say thatthey do not know the regulations intheir state, Dr. Frank said.But he said such results betraya silver lining because clinicianssay that they would be inclined touse a family tree–style hierarchy indeciding with whom they shouldContinued from page 1speak about end-of-life decisions.Hospitalists should at least knowwhether their hospital has a policyon unrepresented patients, Dr. Franksaid.“That’s your road map on how toedge of life, and a spouse arrives,along with two daughters from outof state who have not seen theirfather in a year, said ElizabethGundersen, MD, director of theethics curriculum at Florida Atlan-Words matter. Inappropriate language can“inadvertentlyconvey the feeling that, ‘They’re givingup on my dad – they think it’s hopeless.’ That can makefamilies and the medical team dig in their heels further.”—Dr. Gundersenget through consenting this patient– what am I going to do with Mr.Smith?” he said. “You may ask yourself, ‘Do I just keep treating him andtreating him?’ If you have a policyat your hospital, it will protect youfrom liability, as well as give you asense of process.”tic University, Boca Raton.“The family requests that themedical team do everything, including intubation and attempts at resuscitation if needed,” she said. “Thefamily says he was fine prior to thisadmission. Another thing I hear alot is, ‘He was even sicker than thislast year, and he got better.’ ”Meanwhile, “the medical teamconsensus is that he is not going tosurvive this illness,” Dr. Gundersensaid.The situation is so common andproblematic that it has a name – the“Daughter from California Syndrome.” (According to medical literature, it’s called the “Daughter fromChicago Syndrome” in California.)“T

the-hospitalist.org 3 December 2019 Unit-based rounding in the real world Balance and flexibility are essential By Tresa Muir McNeal,