I've been thinking a lot about Ms. Melanson, the woman from Alberta who died after receiving the correct dose of infusional fluorouracil chemotherapy in an fatally incorrect short time. Cancer care professionals take their responsibilities seriously and are not known to be infiltrated with ignoramuses or reprobates. This doesn't guarantee that a mistake will never be made; in fact this Canadian tragedy is all the more painful because according to the reports the nurses involved were well-trained. Writing chemotherapy orders is a task that requires the highest degree of concentration. It helps to have standard protocols in place, or software programs that can calculate body surface areas and doses, or double-check the doctor's arithmetic, but these are not infallable. The medical team of doctors, pharmacists and nurses have the ultimate responsibility to ensure that all orders are correct. I personally think of the following checklist when writing chemotherapy orders:
The correct patient
The correct drugs (whether chemotherapy, hormone therapy, biological therapy or targeted therapy)
The correct dose
The correct administration (IV push, IV infusion, length of infusion, route of delivery - i.e. portacath vs. peripheral vein)
Putting this into acronym form I guess I would say, "When writing treatment orders, always check your PDA - Patient, Drug/Dose, and Administration."
This is a good start, but in my opinion it is not enough.
Running a safe and efficient chemotherapy clinic requires a commitment beyond following written guidelines or government rules. It requires an attitude best described in French as engagé, which cannot be learned from a textbook.
Engagé is an attitude of confident concern manifested by a doctor who never tires of re-checking written orders or of discussing treatment details with staff and patients.
It means taking the time to write treatment orders in a place where there are no distractions and where there is immediate access to reference materials.
It is a philosophy of openness, manifested by both physician and office staff. There are no secrets in a good oncologist's office. There are no obstacles to reaching the doctor - no phone menus, no permanent hold, no delays in getting appointments. There is no aura in the office that the doctor is above you and you better well have a goddamn good reason for bothering him or her. Information about the benefits, risks, limitations and side effects of treatment are discussed openly and without bias.
To be committed to Engagé is to ask, "What would I want from my oncologist if it was me sitting in that chair?"
I realize declaring a personal dedication to safefy will not satisfy the cynics of the world, who expect every medical treatment to be eternally perfect, as found in certain "utopian" societies among which the United States apparently does not reside. Such disingenuous solicitude always sparkles when displayed by the "nattering nabobs" of the mainstream media, but in reality it is an illusion. No software program, central planning committee or even nationalization of the health care industry will ever reassure patients that the danger is over. Only individuals, the health care professionals who strive to deliver excellent and safe medical care, can earn the trust of those whom they have vowed to serve.
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My only brush with such a thing occurred when my oncologist delegated the prescription-writing to his new resident, who somehow managed to add 25 years to my age in the creatinine-clearance calc.
The pharmacist at the cancer center had, as usual, compared the scrip to the patient label, and, as it happened to be the day after my birthday, was just mentioning to the nurse that she should wish me happy birthday from the pharmacy when the year dawned on him. I'm perfectly ready to believe he'd have noticed that anyway, but there is some part of me that wonders if I just got really lucky there. Happy birthday, indeed.
Of course, in this particular case, the error would have resulted in a much lower, rather than higher, dosage of the chemo drug. So it's not likely that the drug would have killed me; it is simply a matter of personal horror to think of going through all the misery of a cycle of carboplatin for a great deal less than optimal gain on the cancer. My reaction to this is no doubt colored by the fact that I was also being given Aranesp at the time; the odds that I suffered through that incredible expense and non-negligible misery for no particular improvement seem, after all, to be fairly good.
Of course doctors do not act alone, and I for one live each day in endless gratitude to the devoted and capable nurses, technicians, and pharmacists who constantly provide the saftey net. But if you ask me whether I'd rather have six health-care professionals constantly monitoring me for signs of adverse reaction to a drug like Aranesp, for which I see that physicians were paid handsome sums to prescribe, or whether I'd prefer to see the FDA crack down on safety issues before these drugs ever get to the pharmacy, there's no question. I'm sorry, but it's a false dilemma between engage doctors on one hand and faceless bureaucratic cyborgs on the other. Just as it is false to force patients into either the "cynical" bucket or the "grateful recipients of vowed service" bucket.
I am both a patient and a citizen with ideas about how the economics of medicine and the regulation of risk-taking need to be addressed at a level of public policy. I do not stop being a thinking citizen while I am hooked up to the IV pump. Surely you would not wish me to do that; such would be the sign of premature mental death, if not physical death. I therefore hope that when you ask what you would want your oncologist to do for you, you do that on the assumption that what would be sitting in that chair is a complex human being with ideas about the world that are not exhausted by "whatever helps me personally and screw everybody else right now." I can attest to the fact that having cancer makes you rather self-involved, but I don't know why we wouldn't want to fight that as much as we want to fight the disease. If you wish to keep the issues focused on the moral behavior of the individual participants in the oncologist's office, that is your right and a defensible position. If I wish to broaden the issues to ask whether what is the enemy of the good here is not "perfection" but profit-seeking from drug and equipment manufacturers, that is also a defensible position. I think calling it "cynical" is, well, cynical.
Nurses were criminally negligent and should have been sentenced to the same penalty as a drunk driver who kills.
Actually they should receive stiffer sentence because they are held to a higher standard than a worthless drunk.
Sometimes even the most wary patient can be sliced down by errors. :( I do not have cancer, but as a adrenal insufficient Cushing's patient I'm accustomed to being misunderstood, misdiagnosed and mistreated when I am not asserting myself. I can't imagine how a person could avoid the error that was made unless they completely educated themselves on infusion therapy and the precise drug she was given. But who does that? I think it takes a lot of experience and fear to look a nurse in the eye and question their judgement, when you are in the moment.
Even I have some reservations of browbeating the staff and years of Cyshing's has almost beat me. I have had to learn laboratory procedures and get the guts to make unwilling techs to do them correctly, otherwise I am wasting my time. You wouldn't believe the percentage of phlebotomists that do not know the elusive nature of ACTH and proper handling methods. Until you have had an appendectomy in a failed bid to cure an adrenal crisis, you don't know how to fear an Emergency Room. However, the last kidney infection I had I was stuck seeing my regular doctor's officmate. She gave me a drug I do not usually use to clear up the infection. I reluctantly accepted it with some complaint but didn't look it up. It threw me into a fast and hard adrenal crisis. I assure you that it was a lucky thing that my 2-1/2 year old daughter held my hand and helped me to my medicine. But what can you do? I suppose I have a PDR for a reason, but the doctor said it ok. ?
Lisa