Quality Update

Peter Pronovost, M.D., PhD, Medical Director, Center for Innovation in Quality Patient Care

There is no better way to explain what patient-centered care means than to recall a story of compassion and understanding that I witnessed recently between a nurse and her patient. The patient (we’ll call him Jim) died in his wife’s arms as they both lay in his hospital bed in the intensive care unit. Being able to hold her husband gave Ann (alias) great comfort and meaning, something Diane Rusnak made possible through her courageous and remarkable work as Jim’s ICU nurse. 

This compassionate finale began over six months ago in the surgical ICU. Jim arrived there with sepsis, a complication following his kidney transplant. He had battled more than six life-threatening events, but this last crisis was different. An infection was raging within him, and Jim’s medical care team was losing the battle to save his life. 

The team included Robert Montgomery, the surgical attending, Edward Kraus, the transplant nephrologist, his nurse, Diane Rusnak, and me, the ICU physician. Realizing that Jim was sliding downhill quickly, we decided to meet with the family to discuss his prognosis and goals of care. Rusnak, who had more than 10 years of nursing experience, recognized that Jim’s dialysis machine and heating blanket were physical barriers for his family. She proposed removing both, and the family readily agreed. This insightful and compassionate suggestion permitted Jim’s family to draw closely around him, touch him and celebrate his life.

 Rusnak then prepared Jim’s bed to make room for his wife. Though Jim was unconscious, Ann knew that after many years of marriage, he would sense her touch. She laid in bed with Jim for hours until eventually he passed away peacefully in her arms. 

In my seven years of attending in the ICU, this was the first time I saw a family member so involved in patient care. Rusnak is a hero to me, for she taught me what it means to practice patient-centered care. We use this phrase often and loosely, but few of us comprehend its true meaning. I am beginning to understand that it means many things. First, it means patients should be united with their loved ones. Our ICUs are now embarking on an effort to accomplish this by making visiting hours more flexible. 

Patient-centered care also means organizing health care around patients rather than caregivers. This means involving patients and family in all aspects of medical care, including medical decisions. Ann, for example, was very involved in decisions regarding Jim’s medical care and many times pushed physicians and nurses to ensure that he received the best possible care. At first her assertiveness was felt to be offensive, but on reflection the team knew that she brought an important perspective that needed to be considered. She provided the love, comfort and intuition that no machine, drug or care provider could mimic.

Rusnak recognized this care that only a spouse or other close family member can provide.  She showed us that patient-centered care can take on many faces that go beyond a clinical procedure or therapy. Our work must strive to relieve the physical and emotional pain and suffering our patients and families experience that no dose of morphine can dull. Rusnak and many caregivers like her bring this reality to the forefront daily and remind us that we are guests in the lives of our patients. 

What does patient-centered care mean to you? I am interested in hearing your stories. Please share them with us so we can pass them on to others and better understand the many faces of patient-centered care. You can e-mail your stories to CIQPC@jhmi.edu.