For all the benefits that come with technology in healthcare, sometimes there's no replacement for a little dose of humanity.
Never was this more apparent than after media reports surfaced earlier this month that a physician used a video connection to tell 78-year-old Ernest Quintana he was close to death. Quintana had been hospitalized at a Kaiser Permanente hospital due to progressive lung disease, according to reporting from U.S. News and World Report and CNN.
Quintana’s granddaughter, Annalisia Wilharm, who was sitting by her grandfather’s bedside in the ICU at the time, told media outlets that hospital staff rolled a machine into the room and a doctor appearing via a livestreaming video link told Quintana that no treatment options were left. He died the next day.
"We knew that we were going to lose him," Wilharm told CNN in a phone interview March 9. "Our point is the delivery (of the news). There was no compassion."
It served as a stark reminder in the medical community of what could be lost in replacing doctors with technology.
“It was a mess—a moral mess,” Arthur Caplan, Ph.D., founding head of the division of medical ethics at NYU School of Medicine in New York City, said in an interview with FierceHealthcare. Caplan said telemedicine certainly has a future, but in a circumstance such as the one involving Quintana and his family, common sense should have prevailed.
My heart broke because a live streaming image of a doctor told a hospitalized Ernest Quintana that he didn’t have long to live. In response @Medium, @ArthurCaplan & I recommend that hospitals adopt an informed consent policy. #ethics #telemedicine https://t.co/sw3b0iMB8A— Evan Selinger (@EvanSelinger) March 12, 2019
The importance of the 'human touch'
In a statement, Michelle Gaskill-Hames, R.N., senior vice president and area manager for Kaiser Permanente Greater Southern Alameda County, said she wanted to correct news media reports that a “robot” delivered the news. She said the hospital was “deeply sorry for falling short of the Quintana family’s expectations” and that officials had reached out to the family to address their concerns.
“It is important to understand that we do not have robots that have medical discussions with patients or deliver terminal diagnoses. The evening video conversation was a follow-up to earlier in-person physician visits and was not used in the delivery of the initial diagnosis,” Gaskill-Hames said.
The hospital used the video connection to “provide an urgent evening consultation with a specialist physician,” and a nurse was in the room to accompany the video conversation, as is the hospital’s standard practice, she said.
But experts like Dave Levin, M.D., chief medical officer of Sansoro Health and former CMIO for the Cleveland Clinic, said the situation raises critical questions about the use of technology in patient care.
“As a patient, and as a member of a family, I think that healthcare is one of the most sacred things we do in life and it’s often at a critical moment in our lives," Levin said. "People want time, attention and compassion. In-person is almost always going to be best.”
It's an opportunity for doctors and hospitals to review how they use telemedicine and decide what kind of information they should communicate by video to guarantee patients the compassionate care they are seeking, say medical ethicists and telehealth experts.
When they do use telemedicine, how they can preserve the “human touch” at the core of medicine?
“In general, when you are dealing with a dying patient and family you do not want to do anything except face-to-face, personal contact," Caplan said. "That’s got to be the default, the presumption. People expect personal conversation at moments of crisis."
If doctors and hospitals are going to use a video link, “it better be perfect. This wasn’t,” Caplan said. For instance, medical professionals need to make accommodations for patients with hearing or sight impairments.
Some patients may prefer a virtual visit, even to deliver serious news, to stay in the comfort of their home and close to family, but patients and family members should ultimately make that decision, Levin noted.
Like Caplan, John Banja, Ph.D., a medical ethicist with Emory University in Atlanta, was careful to point out the benefits of accessibility telemedicine offers patients and brings medical expertise to communities.
“I think what this case brought up is that there may be certain clinical situations in which this technology might not be advisable,” he said. “Clearly, you cannot hold a patient’s hand. You can’t gauge the emotional atmosphere of the room because maybe you are hundreds, if not thousands, of miles away. For a very emotionally fraught conversation, telemedicine might not be the way to do it."
The lesson for other providers
Many physicians are still slowly getting on board with the expanding use of telemedicine, said Todd Czartoski, M.D., a practicing neurologist and chief medical technology officer of Providence St. Joseph Health, a Renton, Washington-based health system operating 51 hospitals.
“I still run into doctors who say 'that’s not medicine,'” he said, noting younger physicians are often more comfortable using it.
One way or another, the use of telemedicine is expanding everywhere. PSJH has more than 60 clinical use cases for telehealth services, and obtaining consent from patients is a key priority, he said. The health system has set protocols for what is and what isn’t out of scope for telehealth visits, and it varies by service line, he said.
But the viral story of Quintana’s experience gave Czartoski pause.
“My immediate thought was, 'How does this apply to the 40,000-plus visits that PSJH does virtually every year in our hospitals and clinics? Could this happen in our ecosystem and are our safeguards adequate?” he said.
In cases where physicians know they have to have a difficult conversation with a patient, it’s customary in most hospitals to have a social worker, nurse or hospital chaplain in the room to offer support to the patient.
There are situations where technology can actually bring humanity back to the patient, according to Tim Peck, an emergency room physician who co-founded startup Call9. Peck’s company uses telehealth in the nursing home space to provide facilities with 24/7 access to palliative care physicians. As part of the service, the company also embeds a paramedic, ENT or nurse in the nursing home to provide in-person care.
On average, nurse to patient ratios in nursing homes are 1 to 36 and most do not staff on-site physicians, said Peck, who lived in a nursing home for three months before creating Call9. Through the telehealth service, remote palliative care physicians provide acute care services and have goal-of-care and end-of-life discussions with patients and family members.
“We get a letter at least every few days from a patient or family member saying 'Thank you.' We get invited to funerals, we get invited to memorial services, we become part of that experience, and it’s a beautiful thing of what we do,” Peck said.
Banja says he will not be surprised to see national organizations come forth with some guidelines on telemedicine use.
“Whenever you introduce a new and powerful technology ... you’re going to have a learning curve,” he said.
He compared it to the decisions doctors have to make about how far to go in using technology to keep patients alive in the ICU. For some patients, depending on their circumstances, using that technology is not appropriate.
“I have a hunch there’s going to be national conversation about these technologies,” he said.