Hospital Doctors Botch Even Death Certificates

That is right! Doctors working for hospitals cannot even get the cause of death correct in about 54 percent of the cases. Granted this was in the hospitals in the City of New York, but still folks this is bad. The two studies of doctors in the New York City teaching hospitals are not painting a confidence builder. The studies were published in the May issue of the journal Preventing Chronic Disease.

The studies reported what researchers have suspected: that heart disease is over reported as the cause of death, while diseases like pneumonia and cancer tend to be under reported. The findings from one study reported that the health system is far too cavalier about the accuracy of death certificates.

This study surveyed resident doctors in specialty training in 26 hospitals where about 40 percent of the city's deaths occur. The respondents included 521 residents and 54 percent declared they had knowingly reported what they believed was an inaccurate cause of death. One-third of the respondents believed that health system accurately documents the cause of death.

I know from overhearing three doctors talking about what to put on death certificates is always the same – heart failure. One doctor said that is true, because as long as the heart is functioning they are not dead. The second doctor said that is the reason he only reports heart failure and the third doctor mumbled he would need to think about this. The other two asked what he meant. The doctor said that heart failure was often caused by other conditions, and while it may be the last organ to fail, it was not the cause of death. The other two doctors laughed and said why not take the easy way – the person is still dead so what difference did it make.

The second study followed doctors in the same program, but dealt directly with the issue of over reporting of heart disease as the cause of death. This happens often in older patients and while heart disease is considered the leading cause of death in the USA, doctors often list it by default without considering other possibilities. This lack of caring on the part of doctors tends to obscure the statistics of other serious diseases.

One problem I can see is our certificate of death. The form needs revision and needs to reflect secondary illness or disease and possibly more. The form needs to be uniform across all states and copies signed by the doctor sent to the CDC, local courthouse recorder, and given to the administrator or court appointed administrator. Then anyone requesting copies of a certificate of death would receive a copy of the original and the form used by the state or county of residence.

Hospitals Are Even More Greedy Now

I dislike saying this, but I read so much lately about the monopolistic and greedy actions by hospitals that I must express my feelings. Hospitals are under pressure from the Center for Medicare and Medicaid Services (CMS). Instead of working to become more efficient in medical care, give proper discharge instructions, eliminate unnecessary tests and procedures, and reduce readmissions, many are making no changes, or actually doing more tests.

Instead, hospitals are cutting staff, reducing work hours where they can to eliminate paying for medical insurance and other benefits, and they are increasing tests and billing at an ever-increasing rate. Hospital administrators are increasing their salaries and when possible their bonuses. Hospital boards are not enforcing efficiencies, patient safety, and are looking the other way when it is convenient. Even hypothesizing like this blog won't do any good, as the hospitals do not want to work for efficiencies.

Hospitals are now gaming the system and working with ambulance companies to transfer patients that would be readmissions to a neighboring hospital. How far will this go before CMS realizes this is happening? The ambulance drivers know how far it is to the different hospitals and will contact one hospital and ask if this is a readmission and do they want the patient taken to another hospital that is only a few miles further. The hospital says the emergency room (ER) can't handle another patient so that the ambulance company can legitimately take the patient to a further hospital. If the patient is beyond the 30 days or not a readmission, they say they have room in the ER. You can be assured there is a payment being made to the ambulance company.

The other game that hospitals have played for years, but will become more common will be admitting the patient as an outpatient or for observation instead of admitting the patient as an in-patient. This means that the full bill will fall to the patient because insurance does not cover hospitalization as an outpatient. This will add stress and often cause the patient to file bankruptcy.

Will hospitals learn from their mistakes? A few will, but most are profit crazy and have an attitude of milk the cow as long as they can. When the cow dries up, find another cow to milk is the attitude of many hospitals. That is why they have cut so many employees and are running on short staffs, as this is the way they cut costs rather than look for places they can become more efficient and eliminate costs.

Hospitals Set People Up for Readmissions

Some call it hospital readmissions and others name it post-hospital syndrome. Either way, most patients have little control over the situation and hospitals are actually setting up patients for this. Some claim that hospitals are doing this on purpose and others say it is part of our health uncaring system. The following are some of the major causes bringing people back to the hospital:

#1. Sleep deprivation and at the same time a disruption of normal circadian rhythms. Hospitals are noisy, and lights are always on at some level. This means melatonin production is minimal. Even if you fall asleep, a nurse or nurse's aide is always there to wake you for blood pressure measurement, to draw blood, give you a medication, or an injection, so you can forget sound REM sleep. This disruption can be debilitating, and the sleep deprivation can adversely affect metabolism, cognitive performance, physical functioning and coordination, immune function, normal blood clotting mechanisms, and cardiac risk. Yet, the hospital won't consider your feelings.

#2. Poor nourishment. Hospital food by most standards is poor and essentially lacking in taste, nutritional value, and what is called building blocks to help the patient heal and repair the body. Dietitians think they are doing right by providing an unreasonable ratio of carbohydrates, fat, and protein that is supposed to provide sufficient calories. Many patients are unable to eat because of fasting requirements before procedures while other patients have a loss of appetite after surgery, or because the food is so unappetizing. Generally, one-fifth of hospitalized patients over the age of 64 consume less than 50 percent of the nutrients recommended to maintain their energy requirements.

#3. Pain and discomfort. This is one of the more serious problems of being in the hospital. Either you are over medicated or under-medicated. This is a problem for many hospital patients. This can lead to sleep disorders, mood disturbances, and impaired cognitive functioning. Chronic low-level pain is also known to negatively impact immune and metabolic function. In addition, pain medications can further compromise cognitive function. Patients are often given sedating painkillers or other medications that can leave them confused, or even delirious, especially in the unfamiliar surroundings of a hospital

#4. Dealing with a baffling array of mentally challenging situations. Hospitalized patients often meet a variety of health care professionals, but they are given little time to learn their names or understand their roles. Schedules are often unpredictable, and in-patients who are already under stress, information overload can be stressful in and of itself and may even provoke confusion. These stressors of hospitalization can cause delirium, which is associated with increased risk after discharge. Patients in this state of mind are in no condition to understand discharge instructions, such as how to keep wounds clean or when to take medications. It is easy to see how these patients can quickly deteriorate and need to be readmitted.

#5. Medications. As mentioned in #3 above, medications can alter cognition and physical function. In addition, medications to treat symptoms can negatively affect the early recovery period. Sedatives, especially benzodiazepines, are commonly prescribed and may become part of the discharge regimen. Unfortunately, under-sedation can cause accelerated breakdown of body tissue, immunosuppression, a propensity to form blood clots, and increased sympathetic nervous system activity, which can lead to increases in blood pressure and heart rate and decreases in food digestion. Over-sedation, on the other hand, can dull the senses and impair cognitive function and judgment and may also lead to post-traumatic stress disorder.

#6. Financial stress. According to a study published in 2009 in the American Journal of Medicine, medical bills result in 60 percent of U.S. Bankruptcies. Even more frightening is the fact that 75 percent of these bankrupt families had health insurance and still went bankrupt. And these numbers have only gotten worse since the recession fully kicked in, most of which took place subsequent to the study collecting its data. That kind of stress can negatively affect all kinds of physical and health problems.

#7. Extended bed rest can weaken patients' muscles and bones. In effect, hospitalized patients commonly become "deconditioned," so recently discharged patients often have impaired stamina, coordination, and strength, which place them at greater risk for accidents and falls. These limitations may also diminish their ability to comply with post-discharge instructions - not to mention the fact that the capacity to resume basic activities or attend a follow-up appointment can be affected.

#8. Discharge instructions are not always complete and often not fully explained. For the elderly, this can be a confusing time and too often the discharging physician hands this off to a nurse and she is not prepared to give instructions. What a mess this can be. I watched a nurse do her best, but she was not given all the necessary papers and even after two phone calls could not finish. In addition, for the elderly, they may not be in any condition to understand and still be under mild sedation that has not wore off completely. And without a ride, the patient is expected to drive?

#9. For the elderly, often no instructions are given to their caregivers. This is where the elderly are most often discriminated against. I have witnessed nurses cut off caregivers who had proper documentation, such as medical power of attorney and even full power of attorney, by just saying that HIPAA did not permit them to discuss this with them and walk away. Often this means that the patient and the caregiver were not given any instructions about home care and instructions to see the patient's medical provider. Some caregivers learn the hard way and others figure out that certain things need attention and that the patient needs to see their doctor.

Is This Another Form Of Medical Rationing?

Researchers did not do this study justice. They had the opportunity, but apparently chose to leave a lot out to spur speculation like I did at first. When I first read this, I was very angry. With the care in the local emergency unit being so variable depending on the doctor on duty and level of expertise and experience, I thought that trauma centers would be much better – wrong.

About one quarter of 87,754 trauma patients or about 22,000 being elderly, this is a sorry statement that only nine of 131 trauma centers in the US were highly rated for care of the elderly. Then to say “in the study we showed that although some centers demonstrate high performance overall, these same centers might not be providing the same high-quality care to the elderly," really lays the fault on the trauma centers and their administration and staff.

This statement "We've shown that elderly patients have different needs from young patients. Centers need to focus on the needs of the elderly specifically in order to improve their quality of care," defines problems in general for trauma centers. When trauma centers are not prepared to deal with the elderly who may have heart disease, lung disease, or diabetes, this shows how ill prepared the staff is or that the training is totally inadequate for the situations trauma doctors face in the trauma center.

Why did I use the title I did? Because this is a situation where there are many places to find fault. First, I am confident that the level of Medicare reimbursement is very low, which means that the trauma doctors are not wanting to spend much time on the elderly. This also means that the administration of the trauma centers are also discouraging doctors from spending much time on the elderly.

To me this means medical care rationing by Medicare. Yes, I am in this group that Medicare will be limiting care for and I am still angry. I can also guess that the “baby boom” generation following me will not be happy with this and will be even more vocal. This is why I place most of the fault and blame on Medicare for encouraging this rationing of medical care.

Now the other areas that can be creating problems and deserve a portion of the fault. It seems that the training received for trauma doctors is lacking for the elderly and they don't have geriatric training for dealing with the elderly. Their training may also not involve dealing with the elderly that have chronic diseases. So I would think that additional training should be necessary.

With the new Affordable Care Act (now unconstitutional), these concerns will continue to mount for people age 65 and older. You know that the governments at the local through federal will be receiving complaints and if care continues to be rationed, voters will insist on change.

Read about the study here.

Patients In ICUs at Greater Risk

The arguments are being played out and the patients are the ones who will not benefit. Not that the doctors or residents (in training) will fare that much better, but the biggest loser may be the hospitals. They may force both doctors and residents out as they try to keep costs down in that area while raising daily charges for ICU rooms and supplies used in ICUs. Plus hospitals seem to be encouraging doctors to over prescribe medications when patients are dismissed from ICUs.

Now that the Supreme Court has spoken on residents hours and the OSHA is about to make other rules into regulations, if hospitals do not hire more doctors for handling patients in the ICU, the hospitals will lose doctors and patients and may not be able to recover from the downward spiral. Not only will people not trust the ICU but doctors will not want to work there and patients may start requesting to be taken to other hospitals.

That is what is causing the headlines like the article that got me on this topic. Yes, I agree attending physicians are probably putting in far too many hours to the detriment of the ICU patients. But really, where does the fault lie. Doctors are human and start making mistakes after working too many hours. Again, why are they working these long hours?

It is because the hospitals have restricted the number of doctors in ICU. All the studies done will not convince me otherwise. Also most of the physicians are blaming the curtailing of resident hours (or interns) for the problems of working more hours themselves. I realize that the physicians are not going to bad-mouth the source of their pay check, but someday they may be forced into this by rules and regulations.

Hospitals need to realize that if they don't adequately staff ICUs and other places, lawsuits may soon be directed at them and not the physicians. This seems presently to be a no win situation for patients in ICUs. This needs to end.

Read the Medscape article here.