I’m often disappointed by the discharge instructions that I print out to send home with patients. They are canned summaries of particular diagnoses which often do not begin to describe the specific illnesses of the patient. Furthermore, they are often burdensome in length and detail. I think many patients look at the pages of information that vaguely apply to their situation and either throw them out or stuff them in a file, never to be read again.
So what’s wrong with the way that we do discharge instructions in the ED? Here are a few thoughts.
We give the discharge instructions as we are rushing the patient out the door. It’s ironic that patients complain the most about long waits with little explanation about what’s happening and we shrug our shoulders – that’s just how it is, right? Then at the very end of the visit we suddenly release a deluge of paperwork that explains their condition then lists all of the vague reasons for return.
I myself am guilty of putting painfully general instructions for return. “If you have a return of abdominal pain, vomiting or high fever or if you have any other concerns, return immediately to the ED.” ANY OTHE R CONCERNS? Do I really mean that? If they are concerned that they are not able to finish their sandwich at lunch because of fullness in their stomach, do I really want the to return immediately? What if they start sneezing or coughing? What if they sprain their ankle in the parking lot?
How many times have I given those instructions to patients who are still having abdominal pain when they leave? What are they thinking as they read this on the way out the door? Should they just go right up to the front and check back in? Would I welcome them back to be seen again if they followed the directions that I just gave them?
I might not say it but I’d be thinking “Use some common sense. I didn’t really mean to return for any concern. I know you still have abdominal pain, but is it actually any different? Your coughing has nothing to do with your abdominal pain. Your ankle pain may be a concern but does not require a return visit to the ED.”
So if I know these instructions are ridiculous and the patient does as well than why do I still write it out? Who am I speaking to? The simple answer is the unseen lawyer and jury that always are lurking in the corners of a doctor’s mind. Do these vague statements actually provide legal protection if a patient goes home and develops an appendicitis that ruptures? Probably not.
I guess I’m also writing to the occasional patient who:
a. Reads the instructions
b. Follows them
c. Does not have the common sense to return of their own volition without explicit instruction to do so
Every time I write this, I feel foolish but it provides some small semblance of reassurance that I have covered for unexpected events. It is probably false comfort and it almost certainly is not the best way to approach the patients. Ultimately, it erodes my relationship with the patient because at the moment of departure I hand them information that may not apply to them specifically, often gives detailed information that obstructs the most important points, and is shrouded in this vague cloak of legal protection that encourages patients to ignore common sense.
We need to do this better.