Health literacy

A t a Morbidity and Mortality conference recently (M&M), I was presented with a patient who was rapidly decompensating in the intensive care unit, and a decision had to be made regarding CPR, including intubation. During the hospitalization just a few hours before this, the patient had been presented with this information and elected to undergo CPR, but not to undergo intubation. During the course of the subsequent cardiac arrest, when CPR lasted for more than 90 min, the patient received respiratory assistance, but no in-tubation because of his advanced directives. This issue complicated the management of the patient in the intensive care unit when the case was discussed at the M&M today. We were unable to question those who made the advanced directive arrangements with this patient due to duty hour limits. All work in the critical care unit is done by shifts, and the odds of any individual being available on a given morning was less than 50%, as was the case today. In hindsight, it seems unlikely to me that this elderly gentleman understood what was being asked of him. During his advanced directives discussion, what is the proper approach in a situation like this? How much health literacy does the patient need to be able to handle this kind of cataclysmic series of circumstances in a life-threatening situation, in a strange environment, knowing nobody there? I routinely attend around the infamous danger date of July 1st. I have been doing it for years. I feel that my role as a program director should focus on the inpatient service during the first few days with new medicine residents. I have repeatedly noted a combination of resident fears (appropriate) and unfamiliar behavior, including scattered communication skills. Policies and procedures being what they are, mean that there are many things that can be done in any circumstances to try to improve communication. However, the issue of health literacy of the individual is paramount. Health literacy is defined as a level of intelligence and communication skills that a patient must have to make informed decisions regarding what is best for them. For many years, there have been concerns about the lack of appreciation of patient health literacy. In 2006, the Institute of Medicine raised the issue of major problems in providing equal care for all (1). It has been a topic of increasing concern, as studies have frequently demonstrated that …