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Stories Health Care Providers Have Shared

I had an elderly patient with end stage renal disease. He was in and out of hospital 2-3 times with renal failure before I sat down with him and his wife to ask "what matters to you". It was clear that what mattered was for him to be allowed to die peacefully at home, if possible. He had no desire for dialysis or life-prolonging interventions. I was able to communicate this to his nephrologist via faxed letter and she and I had some faxing back and forth over the month before he died but we never spoke directly. The patient was seeing nephrologist and myself over the months before he died, for medication adjustments. CCAC was providing home supports for several weeks before he died. He did end up in hospital because of recurring falls but his wish to die peacefully was respected and he was in hospital less than 24 hours before he died. Monday, a week after his death, I received a Thank You note (handwritten) from this man's nephrologist! A first for me in 35 years of practice. I am sharing this story because I think it demonstrates how a little effort(and it really was little) to communicate amongst caregivers can have a huge impact and is obviously appreciated by our specialty colleagues. This man was not one of "the 5%" but if we can use our health care system more effectively for "the 95%" that is going to have an impact as well.

--Dr Jim Williams, Family Physician


Every time my patient goes to the Emergency Room a different physician see him with no consistency in the care plan for him. There is inconsistency with the different GI residents he sees. Different residents sometimes start a complete work-up that he had before... I wished I had done it sooner... I was frustrated with him and I was frustrated with my inability to help him...

The thing I want to highlight is the absolute importance of the patient's participation in the planning. It seems so obvious but I think we do get a hospital mindset of we're going to tell the patient what to do. So surprise... having the patient involved in every step of the way has been very important. I must tell you, when the specialist got into the room, they didn't have any idea. For them it was a learning experience as well. They were quite grateful for the support we are giving them. So what I think I want to highlight about the process is that is decreased everybody's frustrations to deal with the patient and the situation...

I'm still frustrated with how long it has taken to be able to develop a care plan. It has taken us so long to be able to get everyone together because in the meantime he could de-compensate and end up back in the emergency room. So that has been my frustration in that it has not happened fast enough and I don't mean that... we have been going at it for 5 or 6 months now.

- Dr. Joyce Zazulak


I listened to the doctor and during our first meeting I reflected back to her the significant care that she was offering [the patient]... She has offered to see him weekly, tried to connect him with social work at her office and was struggling to meet his needs. These offers did not materialize into action, however as this individual declined services.. recognizing that the individual who had the closest relationship with this individual was the family physician, she agreed to meet with him and have a frank discussion about his care and concerns for him at her office. She addressed the addiction/dependence issue and he agreed to have weekly dispensing prescribing completed solely by his pain specialist. He agreed to meet at her office with myself and her. We had a meeting where we discussed how to ensure better care from the community to the hospital... these are very early days but in the 4 months prior to our meeting this individual had 5 ED visits and 4 admissions. In the time period following our meeting in July there was 1 admission (and this was in July). Since then there have been no admissions and he is making a plan to return to school.

Key lessons: 1. The most appropriate individual to discuss developing a Coordinated Care Plan and to engage a patient in the process, particularly when they are reluctant, should be the person who has the best relationship with them. This suggests use of a model such as the Integrated Community Lead warrants exploration. 2. We have to address the driver of high service use if we are to make a difference in this area. This mean addressing- with tact, sensitivity and skill- issues that are driving their use of services. Determining what these issues are is likely to be a result of a holistic assessment and engaged conversation with an individual.

- Helen Harris