Doctors Writing Stuff In The Chart That Didn't Happen.

A reader asked me some compelling questions about witnessed fraud and the pain and suffering that's tearing her up inside:

Dear Dr. Happy,

I'm going to get right to the point:  I work with an oncologist who repreatedly writes progress notes on the patien'ts paper chart without having assessed the patient.  I work with another oncologist who gives chemo to dying patients. I'm told by her patients that she says they need it. Recently, one of her patients came to the ER directly from the onc office for SOB experienced while receiving a prolonged chemo infusion. She has widely metastatic non-small cell lung cancer (every organ you can imagine) with excruciating pain.    After a two week intubated stay in the ICU, on four pressors, with an albumin of 0.8, she was discharged to a nursing home unable to do anything.    On the last hospital day, the oncologist wrote a note that the patient "looks great and will be ready for another round of chemo soon".   Looks great?  Greater than what? The family is adamant about 'doing everything' because her oncologist said she was doing better!  This lady can't even move.    This is wrong.  It happens often.  I feel terrible and I'm really distressed. I'm just a nurse.   Do you think I should report what I know to hospital administration?  Should I file a report with a medical ethics organization?  Or should I keep my mouth shut and hence keep my job?  Or should I look the other way and be grateful I have a job?  This is distressing and I can't sleep - - I just feel so miserable.   I need a level-headed, pragmatic opinion.  Can you tell me where I could get one of those?  Thanks very very much. Sorry to bother you, but I had to start somewhere.

You bring up several points worth talking about.  First of all, I too have had nurses tell me they have seen physicians write follow up progress  notes, complete with a history and physical exam, and never enter the patients room.   That disgusts me too.  I don't know what the right option here is.  It's a difficult situation.   You could take your concerns to the medical staff offices at the hospital.   If your hospital has any integrity at all they would  not take your concerns lightly.  There is a possibility you could get "fired", as happened to some nurses in Texas who filed a complaint against a physician,  then got fired, then sued and fought back and as far I I know, won their case.

If the patients are Medicare or have private insurance, both insurance programs have processes in place for filing fraud complaints.  You could go directly to them.  If your employer is the oncologist you're  more likely than not to be let go.  Certainly, you could carry on your crusade as an unemployed nurse.  If your employer is the hospital, bringing up concerns about fraud is something they should want to hear about.  And if they sanction you for your truthful actions, it's time to get a lawyer.   Or you could always tell the doctor up front that what she documented is not what you witnessed and explain your concerns about fraud.  Perhaps she believes nobody is watching and she may just surprise you.  

As far as your concerns about end of life ethical issues, we unfortunately live in a health care buffet where patients and doctors have an all access pass.  As physicians, our only limitation is what we say it is.  It's unfortunate, but when you have  physicians who lack perspective, integrity, common sense and compassion,  they have the ability to offer patients everything, all the time, whether it is medically necessary or not.

I have to ask, Where are all the other doctors?   The best pressure on doctors to behave are other doctors.   Why have they not stepped up and confronted this oncologist with a more rational picture of reality and their concerns about pain and suffering the patient is needlessly experiencing.  Medical inertia is a powerful force.  Once the wheels of doing something, anything, get moving, it's hard nearly impossible to change directions.  What you need is a rational family and a rational physician communicating about dying with dignity.  What your hospital needs is a palliative care team.  I've heard it said before that the ICU team is the most expensive palliative care program out there.  I've heard the same said of oncologists, cardiologists and nephrologists. Even many hospitalists lack perspective.      A real palliative care team is invaluable.   They can and should be asked to enter into the discussion of dying patients to help define the past, present and future goals of the patient and family.  

What your hospital  needs is a team that can help bring an objective truth in to the equation.  What the family hears is not reality.  What this oncologist is telling them is not reality.  Both are living in some sort of fantasy world, or Hell, depending on how you look at it.  Both parties need  redirection.    I wouldn't get into the middle of such squabbles.  It's not a battle I think you can win on behalf of your patients.  You know they are suffering, but the medical opinion of the oncologist will always trump your opinion as a nurse, no matter how right or wrong they are.   What you need are folks on your side, helping you help your patients by overwhelming your patient with an alternative opinion the truth. It's all about truthful communication.  You won't win this battle alone.  

Then it's up to the doctor to stop ordering the pain and suffering, it's up to the insurance companies to stop paying for it and it's up to the patients and their families to accept the reality of the situation.  As long as everyone is fully informed, the chips will fall where they should, most of the time and dying with dignity becomes a reality.   Perhaps some readers have an opinion on what this distressed nurse should do about the documentation fraud she is seeing committed and the pain and suffering she feels is being handed without telling patients the truthful reality of their situation.   On a side note, you can watch my video titled Hospitalist vs Oncologist for a delightful look at cancer care.