Ward patients sometimes comment on, or complain about, the fact that they can hear conversations between doctors and other patients through the curtains. When you’re having a conversation with a patient, you may as well imagine that the room is entirely open plan; curtains provide a visual barrier, but are more of a symbol of privacy, like the sheets hung in overcrowded homes of centuries past. Imagining the bay as a small hall with six or eight beds arranged in it makes you think twice about having any conversations at all, yet to conduct every sensitive conversation in a private room would be impractical. David Oliver touched in this in a BMJ piece last year. Patients would need to be wheeled their beds, or helped into wheelchairs and taken around the corner into a private space, with or without their relatives, on each ward round. Nobody expects this to happen. This begs the question: what kind of conversations are acceptable on the ward, and which should be reserved for a truly private space?
We are used to making special arrangements for breaking very bad news, end-of-life or DNA CPR conversations, and for planned conferences where several family members are expected. To gather four or five plastic chairs around a bed in a cramped space and pretend to be comfortable delving into intimate and existentialists details. But other conversations, the majority, are conducted within in earshot of strangers. Sometimes, a ‘routine’ conversation about treatment (which is still, after all, highly personal), can transform into something else.
Recently, in conversation with a jaundiced, alcohol dependent patient, I sensed a complete lack of understanding about the seriousness of his situation. I was standing next to his bed. Other members of the firm, a nurse, and a student, stood nearby, listening or typing into computers of wheels. We had been talking about the next set of tests, progress, plans. Nothing too personal, nothing too sensitive. Then I took the conversation into a darker place, to emphasise the gravity of his illness.
“I’ll be truthful with you Mr ______. And it’s a lot easier for me to say than for you to do, I know, but if you start drinking again after you get home, you will probably die in the next three months.” It took him unawares. His eyes moistened with the realisation of how close to death he was. The visit ended, and the nurse stayed with him to provide comfort and make our disappearance from the bedside less abrupt. As I drew the curtain back I looked across to the patient opposite, who had of course heard everything. Now he knew as much about the alcoholic patient’s poor prognosis as the patient himself. As patient 2 looked across at patient 1, there was shared, highly personal knowledge. Patient 1 was left totally exposed. It felt wrong. It was wrong. Yet, how could I have done this better? Perhaps I should have paused the conversation and said, “We really need to talk about the future, in private… how about I come back later…” But there was no ‘later’ that day. I could have delegated the task to a very capable registrar, but that also felt wrong. And the conversation just went in that direction, naturally.
Hospital, I have observed over the years, is a harsh leveller. It is difficult for the great machine to tailor and modulate its processes to the individual sensitivities of each patient. What one patient would regard as unacceptable in terms of privacy, another will have no problems with. As doctors and nurses, we tend to apply our own standard to everyone. Yet that standard has probably been lowered by brutal shifts in A&E where people display their vulnerability to all and sundry in waiting rooms and scream in pain or cry inches from strangers. It is easy, as a doctor, to think ‘The priority here is treatment, this is a busy environment, dignity comes second…’
Nurses are the guardians of dignity. Yet doctors can with an irritated scowl or a quick glance at their watch, overrule the gentle suggestion that ‘it might be better to have this conversation away from the bedside…’ I know I have done that. A conversation that I think is ‘ward appropriate’ might, in a nursing colleague’s mind, touch on a subject that no other patient should be allowed to hear. Who decides? Does the acuity of the ward, or the incessant flow of humanity through an Acute Medical Unit, justify a reduction in privacy thresholds?
There is no list of topics that should be explored in true privacy. The patient should, in theory, be in control. To discover a patient’s level of sensitivity, it is necessary to ask at the beginning, ‘I’d like to talk about x, y and z, would you rather we did this somewhere else?’ The danger, perhaps, is that they will say yes! Then it will be necessary to move everyone. Universal provision of side rooms would make this all easier, and it is actually a relief to see people in that environment, on haem-oncology wards for instance.
My advice? As ever, it starts with a patient-centred view, and empathy. What would you feel if you were told you have three months to live in a room where five other patients could, if they were alert enough and unable to switch off their ears, hear every word? Like all things in medicine, quality takes more time, more patience… it requires the machine to slow down. That is not always easy.
or see Amazon author page