Finding Alignment under Conflict to Change a Law

What happens if someone who is dying no longer wants food or water and can’t communicate this? What if the food or water is causing pain, breakdown of tissues, and increased suffering?

In the mid 1990’s, medical ethics emphasized patient choice and autonomy for quality of life and care in the last months of life: a patient should have the quality and the care s/he wanted. New York State’s law dated back several decades, to a time before ICU care or the modern conception of end-of-life care. It forbade removal of artificial hydration and nutrition.

What if the patient didn’t want them or the treatments were harmful? If a patient couldn’t communicate, they stayed – no matter prior conversations with doctors or with the medical proxy set up by a newer NY State law. Some hospitals and nursing homes felt the law allowed them or required them to impose their religious and moral beliefs on all patients in their care.

The bioethics committee of the state medical society debated the issue for two or three meetings. The committee consisted of 30 physicians, from academia, private practice; researchers on medical ethics, lawyers, administrators, and religious leaders. A few members of conservative religious and political backgrounds argued adamantly that the law could not be changed. Most of the liberal group couldn’t see a reason not to change it.

A year later, the state legislature and the Governor decided to revisit the law. They needed a decision of this committee: yes or no? We re-opened the debate. Again the conservative members dug in their heels. Again, the liberal majority couldn’t understand not updating the law.

When I explored, we all saw that each of the liberal members had withheld food and water when they thought that was the correct thing to do, ethically and medically. Had there ever been individual circumstances when the conservative physicians had withheld tube feedings or intravenous fluid from a particular patient who was dying?

Yes, they had often taken subtle cues from individual patients and then ceased artificial support. For example, a elderly man might tug at his nasogastric tube angrily to try to pull it out, over and over. Clearly he didn’t want it anymore; it was removed. An elderly woman consistently pushed away the baby-bottle full of Ensure given to her to suckle. Again, the sign was unmistakable and feeding was stopped.

The group in the minority could not imagine such subtleties being enshrined in law. That was the real issue.

I got unanimous consent from the committee to state this entire position as our consensus to the government: “a minority did withhold food and water in individual cases but believed the reasons too subtle to be enshrined in law; the majority thought the law should be changed.”

This I testified about in detail before the legislature and the Governor’s staff, being compassionate and truthful to both sides. The law was changed to allow patients and their proxies to withhold unwanted or harmful care, no matter the ethics or religion of the institution they were in.

Finding the Alignment under a Conflict over Vision and Drivers

Need for Modern Driving Regulations

What kind of vision cards should be used to test people for a driver’s license? In the late 1990s New York State’s Department of Motor Vehicles (DMV) used cards like those in a doctor’s office. There was a large black letter at the top, and, descending row by row, smaller and smaller, less and less black letters ending in a line of really tiny letters.

These had practical and theoretical problems – not as used by a doctor or an optician, but as used to qualify drivers. A driving applicant would read the card with one eye, moving to successively smaller print, and then do the same with the other eye – but the applicant had already read the card and could give correct answers with the second eye for a line of print the second eye couldn’t see clearly. There were other problems: for example, the way light fell on a card in one corner of a DMV office instead of another part could affect whether an applicant would pass or fail.

Members of the Vision Committee were at loggerheads.  The committee had half of the newly-formed Medical Advisory Board to the NYS Department of Motor Vehicles. The Department’s Commissioner and senior staff needed the Board’s input to craft new regulations and to defend them to the State Legislature. This was the first question the Commissioner and his staff had posed to the Advisory Board.

The question was whether or not to move to an entirely new form of vision cards. Newly  published work in the medical-scientific literature showed that a different kind of card was more accurate for driving tests, less influenced by variations in lighting, and less susceptible to cheating.

The new cards had 5 or 6 lines of  5 or 6 letters, different letters in different orders,  all letters the same size. The lines were chosen arbitrarily from the entire set of combinations of 26 letters taken 5 at a time in whatever order. The print size was the minimum an applicant had to be able to read standing at the DMV counter and looking at the card to show vision was sufficient for driving.

The DMV agent would pick out a line at random – “please read line 5 with your left eye,” and then another, “now, line 2 with your right eye”. No one could learn all the lines while concentrating on one, and there were too many variations in cards for anyone to memorize them ahead of time.

The Advisory Board had a mixture of professions. There were one or two physicians, research workers and other healthcare providers in each of the specialties the Commissioner thought would be helpful; representatives from state agencies dealing with aging, social services, and public safety; and representatives from enterprises and institutions throughout the state concerned with driving or with illnesses that might influence driving, the American Automobile Association for example. We were all assigned to one of two committees, Vision, and Loss of Motor Control (seizures, epilepsy, diabetes, sleep disorders, muscle disease).

I’d heard about the bitter division in the Vision Committee and as chair of the other committee, outside the conflict, I offered to help.

The first observation was that the physician-healthcare provider-scientist group were unanimously for the change. They had found a series of good, published research pointing to the need for change and to an effective method. They had not found anything that disagreed with these papers. They went through the articles with me and showed me why they felt this way.

The other representatives were all adamantly opposed, the ones whose background was in law or policy, not medical research. I asked, “why don’t you like the proposed change?” They pointed to the discussion section in the two most important papers. The authors had written that theirs was only one study, and the results should not be accepted until other laboratories had replicated the work. They had studied only a limited number of people – enough to give statistical validity, but perhaps a larger study would give different results. They had studied people of only one or two racial and ethnic groups living near their research center: things might be different with other groups in other parts of the country: “more research was needed.”

“See,” the  opponents said, “the scientists themselves don’t believe their conclusions are warranted.”

I explained. If the authors of a scientific paper did not put in disclaimers, editors and readers would worry the authors had been biased in favor of the what they found even before they started the work. People would worry the authors might have ignored details and information contrary to their conclusions. Any piece of research is considered interesting but it is not definitive until other groups, somewhere else in the world, have duplicated the results. Almost all scientists want to continue to have funding for their work  – these last sentences were code for “please give us additional funds so we can do more and learn more.”

Once the non-medical members understood the conventions of scientific work and writing, they agreed that the new system made sense and had clear advantages over the old. The committee wrote a unanimous recommendation to the Commissioner. The new cards were in use throughout the state within a few weeks.

 

 

 

Motivated Failing Toastmasters Clubs to Succeed

Motivated failing Toastmasters club to succeed by inspiring members to align purpose, mission, and activities; and coached a club that had failed with an earlier coach to achieve Select Distinguished status, the second highest club award:

In Toastmasters clubs,  members teach each other to improve public speaking skills and to develop leadership skills. The Toastmasters International (TMI) vision describes reality: “Toastmasters International empowers people to achieve their full potential and realize their dreams. Through our member clubs, people throughout the world can improve their communication and leadership skills, and find the courage to change.” (TMI website, http://www.toastmasters.org/Members/MembersFunctionalCategories/AboutTI/MissionVisionandValues.aspx)

One club near me was sliding towards failure because the two people were doing all the work and were burning out.  Another club was failing by having too few members, and continued to fail despite nine months’ work by another coach and Division officers. I present these problems together because I used similar methods to change matters.

Clubs are ranked each year by TMI by objective criteria that measure how much the club provides for its members’ success: not rated, Distinguished, Select Distinguished, and Presidential Distinguished. To succeed, each club needs enough members to spread work from meeting to meeting over the 6 months of each term and to provide a variety of perspectives in speeches, evaluations, and leadership. New members need to join to bring in new ideas and to replace members who leave.

In 2008, I was Area Governor for a group of Toastmaster Clubs.  The task was to help each club, to build on its strengths, to succeed, and to flourish. The first club was failing because there were only two committed officers.  They took most of the 7 or 8 roles in each meetings and they were getting tired and discouraged. Yet there were 20 or more members and new members joined at almost every meeting.

After attending several meetings and establish rapport, I got the club’s permission  to take half an hour at a meeting to discuss the club. Everyone gave input on what was important to them about a Toastmaster club and why.  We explored why each of those answers was important. I was careful not to comments myself except to agree and ask for more input.

The process inspired members to take on roles, to run for office and work hard at the officers’ duties. It inspired the exhausted officers to continue and to delegate. The Division Governor and I trained the new officers of the club. I continued to attend club meetings, and when asked, made suggestions from which the club chose solutions. Key members of adjacent clubs agreed to participate in meetings to set examples and they agreed to hold joint meetings. By the end of the year, the club was succeeding and now, three years later, it is flourishing.

In late January, 2010, I was asked to coach a club that had failed, and that again failed despite nine months’ work by another coach and Division officers. Clubs should have 20 members; this one had only four. It needed at least 13 to continue. After establishing rapport, I asked them what was important and why,  aligned them to want to succeed, set examples at meetings of how fill roles; and when asked, made suggestions from which the club chose its solutions. By late June, 2010, the club had 15 members and was Select Distinguished, the second highest level of excellence.

 

Saved 4-fold ROI by Aligning a Team

Saved medical center hundreds of thousands of dollars annually by reducing patient re-admission rates from 20 per month to almost none, by creating a high-performance 10-member team and aligning them to use modern treatments:

Patients with epilepsy at a major hospital in the South were being readmitted almost every month. They were either having break-through seizures or complications from their medicine.

Break-through seizures come despite someone taking  a seemingly correct dose of an accepted medicine. Sometimes a second problem has come up: stress, another illness. Sometimes the medicine isn’t really the right one. Sometimes the medicine isn’t monitored and the patient is actually getting too little or too much. Sometimes a well-meaning healthcare provider, untrained in neurology, adds a second medicine arbitrarily because the patient had a breakthrough seizure, so the seizures come more often and are more severe.

The treatments at this hospital were within accepted national standards, but the details were outmoded. Several problems were occurring and reoccurring.

The hospital wasn’t using the newer medicines which had fewer side-effects and fewer break-through seizures. Doses weren’t being monitored: neither blood levels in the morning before the first dose of the day, nor patient’s or the family recording on a calendar each seizure, (with a note of other matters: a cold. flu, an argument). ER doctors and nurse-practitioners merely increased the dose of the medicine after a breakthrough seizure was on, or added a second one, without getting advice from a neurologist.

The medical center asked me to create a new neurology service with 18 inpatient beds and a weekly clinic. There were excellent nurses, therapists, social workers, neurologists, and residents to staff it. They needed to be formed into a team, aligned, and inspired to high performance. Of course each one had been taught in school or early in clinical training to care for epilepsy, had done it for years, thought they knew how, and were no more interested in change for change’s sake than anybody else.

There was what was done; there was how it was done.

What was done is given below. It’s technical.

How? People on the team were already troubled by the frequent readmissions of  their epilepsy patients. Even the people most adverse to change were willing to try a new approach for 3 months to see if it made a difference. Over those months fewer and fewer patients were readmitted, and as more and more showed up in clinic grateful for the improved control of their epilepsy, the entire team became advocates for the new methods and used them enthusiastically: we developed into an aligned, high-performance team. The team was willing to consider ways to improve care for other neurological diseases.

The patients had better treatment and better quality of life. The readmissions decreased to essentially none. Each readmission cost the hospital thousands of dollars, and the dozens of seizure patients had in total 20 readmissions each month. The new approach and aligned team saved the medical center several hundred-thousands of dollars annually, well over four times my annual salary, a clear Return On Investment.

What was done was discussing and writing down the current, the modern approaches and teaching them to everyone on the team (including the neurologists and residents who rotated in for a month or two). The approaches were 1) using brand-name anti-epilepsy drugs (whose blood levels are more constant from refill to refill than generics), 2) using new drugs for the specific forms of epilepsy they treated best; 3) measuring blood levels before the first dose of the day (“trough” levels) once a month and 4) getting a trough level the morning after any break-through seizure; 5) having the ER physicians call a neurologist about patients who came in with a break-through seizure instead of arbitrarily changing the regimen, 6) adjusting doses so the blood levels were in the therapeutic range, avoiding side effects, 7) using seizure calendars as guides, and 8) following the patients regularly in the clinic.