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Richard Bourne |
My pager goes off and, deeply asleep, I reach for it, thinking how much I hate getting calls after midnight. The clock reads 10 p.m. These days, I'm often in bed early. Splashing my face and trying to read the telephone number, I see that a resident in the Emergency Department is seeking a legal consult.
A 15-year-old Dominican female, accompanied by her mother, has presented with a high fever, perhaps a cold but possibly an indication of more serious meningitis. The mother is refusing a spinal tap and wishes to leave the hospital against medical advice (which we call AMA). Just as clinical management rests on case facts and history, legal advice is dependent upon understanding any situation as accurately and completely as possible. Feeling tension between such an understanding and the crisis atmosphere of the consult, I begin asking questions: "What symptoms have been observed?" "What is the differential diagnosis?" "Is there any way to distinguish the less serious from the more serious condition?" "Are all the clinicians in agreement?"
I'm not a clinician. I'm an attorney at Children's Hospital Boston. I ask the physician to explain his data to me in "lay terms." It seems that there's no way to tell whether the child has meningitis without a spinal tap and, if the child is not appropriately treated, she would potentially suffer significant harm. "What's happening now?" I ask. I learn that the mother is fearful that her daughter is going to die, if not from her disease then from what she feels is a dangerous treatment. "Has Social Work met with her?" "Is Security on notice?" "Are we sure the mother fully understands her child's condition, what we want to do and why? Let's involve Interpreter Services if there's any potential language barrier."
I think of the mother's understandable fears and of my years as a Peace Corps volunteer in Santo Domingo. Though wanting to avoid legal interventions, I mention the possibility of filing a report on medical neglect with the state Department of Social Services and of obtaining a court-issued restraining order prohibiting the child's removal from the hospital. "Is there a Dominican nurse or doctor who can speak with the mother?" "Have we had a chance to review all medical records?" "Is it possible to contact a primary care doctor who knows the family and might reinforce our message and concern?" I can't think of anything else to say and end our conversation with "Don't hesitate to call me again if I can be helpful to you." I learn the next morning that the mother, after further discussion with care providers, had agreed to the tap and that she and the child returned home with a plan to monitor and reassess.
For more than 30 years, I've consulted on patient care issues at Children's. I'm always available by page, unless I'm visiting my grandchildren in China. I'm often on the units, rounding with the treatment team, responding to cases like the teen with an eating disorder who's resisting feedings, the parents who are requesting an intervention which the physicians believe "futile," the divorced couple warring about who should remain at their son's bedside. I get calls about informed consent, confidentiality and disclosure, documentation, treatment conflicts, risk management, litigation and similar issues.
Sometimes the questions are strictly legal, like "What does Massachusetts law require?" More frequently, although legal concerns exist, it's broader in scale: "What are your thoughts about this problem?" My goal is to assist the person consulting me, by explaining the law, by reviewing possible responses and their benefits and downsides. It's often helpful for folks to have someone to brainstorm with—a lawyer who's less directly involved than the consulting care provider, who has long experience in problem-solving and has a different way of analyzing problems. And my best questions remain: "What would you like to do?" "What do you think is best for the patient and family?"
I think all the lawyers in the legal office take the same approach. Broadly speaking, Skip (Stuart) Novick, senior vice president and general counsel, handles institutional matters. Pixie (Edith-Marie) Paradiso reviews contracts and business issues. Pat Taylor is involved with research questions and intellectual property and Ellen Majdlock consults on employment problems. By the way, as you may note, many of us have nicknames. I refuse to disclose mine.
Sometimes lawyers are distant and formal figures who work in elegant downtown offices. At Children's, the staff knows us and usually doesn't hesitate to involve us in cases. Indeed, we're often welcomed and thanked for our advice. For me, it's such a pleasure to attend a case discussion where many of the staff are my friends—or, at least, acquaintances—peoples whom I like and respect; smart and caring professionals who are providing the best possible care for sick children.
Without getting too sappy, I love my job. The work is interesting and varied. I don't have to wear a suit every day or worry about billable hours. And, most importantly, I feel that I'm making a small contribution to an extraordinary hospital and to exceptionally talented professionals who are supporting sick children and their families.
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