God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine

by Victoria Sweet

  Page 229. The Greeks called that emotion eleos: Eleos is “the feeling of pain caused by the sight of some evil, destructive or painful, which befalls one who doesn’t deserve it and which might be expected to befall ourselves … and soon” (Aristotle, Rhetoric, 2:8, 1386a from the online version at http://rhetoric.eserver.org/aristotle/rhet2-8.html. Translated by W. Rhys Roberts).

  Page 235. The conflict between Dr. Stein and us was escalating: For a passionate account, see the “Letter to the Laguna Honda CEO” by Dr. Romero and Dr. Kay at victoriasweet.com. For a summary of the Flow Project and the MHRF, see George Wooding, “LHH Policy Questions—Parts 1 and 2,” January and February 2010, http://www.miralomapark.org/miralomalife/miraloma-life-online-january-2010/ and http://www.miralomapark.org/miralomalife/miraloma-life-online-february-2010.

  Page 235. This was the best place to send those patients at the MHRF: For what happened at the MHRF, see Janice Cohen, MD, “Doctors support Proposition D” at www.beyondchron.org/news/index.php?itemid-3229. The Omnibus Budget Reconciliation Act of 1987 (OBRA) contained the Nursing Home Reform Act, which stipulated that a psychiatric patient could be in a skilled nursing facility only if he had a physical as well as a mental condition.

  Page 237. Using the BioPsychoSocialSpirtual model: For copies of Mirene’s proposal, the response, and Mirene’s response, see the documents at www.stoplhhdownsize.com, and also at the SocialRehabGrant_Application.pdf at victoriasweet.com.

  Page 237. Its report was brilliant: See Health Management Associates, “The San Francisco Department of Public Health: Its Effectiveness as an Integrated Health Care Delivery System and Provider of a Continuum of Long Term Care Services.” For a copy, see www.victoriasweet.com. I have summarized only its most significant points in the fifty-seven-page report.

  Page 238. Citizens for Laguna Honda: For information and documents on Proposition D, see www.sf4LagunaHonda.org. The best source in general, though, for documents and the politics of Laguna Honda is the website run by Patrick Monette-Shaw: www.stoplhhdownsize.com.

  Page 239. Laguna Honda failed its recertification as a hospital: See LHH06report.pdf at victoriasweet.com. I have obviously summarized the most important issues in the 274-page report. It isn’t quite as long as it seems, however, because three of its horror stories are repeated three times in three different places for three different kinds of infractions. Quite a few of the citations are so picayune that it’s hard to believe that there was not a hidden agenda behind the report. For instance, an F250 citation was given for “weight loss” in an obese patient who was dieting. An F248 citation was given because it took two weeks to fix a patient’s television. There was an F252 citation for a wheelchair with cracked upholstery; an F371 citation because a paper-towel receptacle required touching of the receptacle; another because of a soiled oven mitt; and a third for scratched cutting boards. My two favorites are the F253 citation because the solarium was filled with wheelchairs and the F457 citation for our open wards. Regarding the citations for violent patients, all occurred because of patients admitted during the months of the Flow Project, when Dr. Romero’s decision about not admitting certain patients was overruled.

  Page 247. “Mr. Zed wrote a poem for Paul”: Mr. Zed was part of the poetry group at Laguna Honda. There were some very good poets in it, and once a year a booklet is published of their best poetry. With Mr. Zed, the difficulty of having to follow privacy laws for patients comes into focus. The real Mr. Zed naturally wants his work to have his real name attached to it, and so do I. But as his physician, I am not supposed to reveal identifiable patient information. A compromise is that I will put anyone wishing to contact Mr. Zed in touch with him, with his permission. Since I also particularly love his “Letter Needing No Stamp,” I quote it here:

  To His Supreme Holiness, the Lord:

  I sometimes wonder how you can bear

  The dreadful burden of knowing everyone’s thoughts.

  The anguish, the heartbreak, the agony.

  How can you even relax?

  Maybe you try not to get too involved.

  Or maybe you spend all night, weeping.

  Why did you create such a sad world?

  Why don’t sandwiches grow on trees?

  Why do infants die?

  Why do honest people get cheated?

  Why do the poor get crushed to the wall?

  Personally I would turn down your job in a second.

  You can’t buy a pie or go to the movies.

  And there are always people denouncing you and cursing you.

  Some say you had a crazy son who said

  I am the Way and the Life.

  We must all pray that you never resign or become bitter.

  As sad as things seem to be here

  Without you they’d be infinitely worse.

  Thank God for God

  Stay in there buddy

  Have a martini once in a while

  Create a new universe.

  CHAPTER TEN: IT’S A WONDERFUL COUNTRY

  Page 258. And there was a rare form that did affect adults: I thought Steve must have the rare Becker muscular dystrophy, and not the more common Duchenne muscular dystrophy.

  Page 262. The Committee to Save Laguna Honda: See “Proposition D for San Francisco, 2006: Zoning Changes to Limit Services at Laguna Honda Hospital and Other Residential Health Care Facilities” at www.sf4LagunaHonda.org. There were two distinct organizations: San Franciscans for Laguna Honda, which sponsored Proposition D, and the Committee to Save Laguna Honda. Sister Miriam, Dr. Romero, and Dr. Kerr, and Miss Lester, despite her retirement, were members of both.

  Page 263. Chambers class-action lawsuit against the city: See Mark Chambers et al. v. City and County of San Francisco, C06-06346 WHA First Amended Complaint for Declaratory and Injunctive Relief, filed October 12, 2006. It had many subsidiary demands, in addition to those I focus on here, including that the lawyers bringing the suit would monitor compliance and receive up to $200,000 per quarter to do so (27). For a summary of the politics around Chambers, see George Wooding, “Hi Sean,” 2009, and George Wooding, “Laguna Honda Hospital Policy Questions—Parts 1 and 2,” www.miralomapark.org, January and February 2010. For the lawyers’ view, see www.bazelon.org. Bazelon is proud of being the same group that closed the state mental hospitals and is now intent on closing the states’ long-term-care institutions. Some thought that Dr. Stein and the mayor may have helped organize Chambers so that they could save money by downsizing the hospital and using its beds for the homeless. The chronology is suggestive, according to Wooding. A meeting was held at the Office for Disability first with its director, Susan Mizner, the Chambers lawyers, and the Independent Living Resource Center, which would become the organizational plaintiff on Chambers. Right after the meeting, Mizner wrote Appendix A of the Controller’s Report, where she calculated that it would be cheaper to discharge patients than keep them at Laguna Honda. Although she noted that 40 percent of the hospital’s patients had mental-health and substance-abuse needs, she did not include those costs in her analysis and estimated their medical costs as 0. See Susan Mizner, “Estimates for Housing, Medical and Supportive Care Costs for People Discharged from Laguna Honda Hospital,” in Appendix A of Ed Harrington, Controller, “Laguna Honda Replacement Program: Where Do We Go from Here?” San Francisco, May 19, 2005, pp. 7–10, at www.disabilityrightsca.org/advocacy/lhh/HarringtonReplacement.pdf.

  Page 264. Although the mayor and Dr. Stein seemed sanguine about its demands: On the Chambers settlement: “It’s a win for the client and a savings for the city; so it’s a win-win,” Dr. Stein explained to the newspapers. Quoted by Elizabeth Fernandez, “S.F. to Subsidize 500 Housing Units for People Leaving Laguna Honda,” San Francisco Chronicle, November 28, 2007. The seventh plaintiff on Chambers was the Independent Living Resource Center, whose head also sat on the mayor’s Long-Term Care Coordinating Council.

  Page 268. Mrs. Han fell to her death: Mr. Conley’s comments are quotes from the interview,
Dan Noyes. “Feds Investigate Laguna Honda Hospital” (http://abclocal.go.com/kgo/story?section=news/iteam&id=5133815), [March 19 2007]. The doctor’s comments are from follow-up reporting also by Dan Noyes. “Did Budget Cuts Lead to Patient’s Death? Doctor Offers Insight” (http://abclocal.go.com/kgo/story?section=news/iteam&id=5135013), KGO, 2007 [cited March 20, 2007]. It also describes Noyes’s attempt to interview the mayor.

  Page 269. The Wall Street Journal contacted Mr. Conley: For the resulting article, see Lucette Lagnado, “Battle on Home Front,” The Wall Street Journal, May 7, 2007. Since Ms. Lagnado interviewed two of my patients, I tried to contact her in case she might want to understand their medical issues. She did not return my calls, and she did not get their stories right.

  Page 270. One hundred thousand dollars turned up in his budget: Mr. Conley revealed the new money for a public relations firm and a media position to the Health Commission on April 16, 2007. The firm, Wide Angle Communications, would “support the hospital’s journey from institution to community,” Mr. Conley said. His announcement of the new Director of Community Relations, Adrian Serf, was on October 29, 2007. Adrian had been the spokesman for the mayor’s transition team and his job would be to “handle negative publicity and improve the hospital’s community and media relations.” For the minutes of these Health Commission meetings, see www.sfdph.org/dph/files/hc/jcc/lhh/minutes.

  CHAPTER ELEVEN: RECALLED TO LIFE

  Page 289. She was of the rare breed of Bad Girl: Bad Girls were just like Bad Boys, only fewer and badder. They used drugs; had been in prison; had acquired numerous drug-and prison-related diseases; been in car accidents; muggings, both given and received; been stabbed and attacked; had undergone many surgeries; and had bad luck. Unlike most of the Bad Boys, the Bad Girls were often prostitutes with all those medical complications, too. However, that was not what made them “bad” in my eyes. What made them “bad” was that they had spunk. They were tough; they continued to live life the way they wanted regardless of the consequences. So, they were Bad in the sense of good, just like “cool” means “hot.”

  Page 289: Now, a stroke on the right side of the brain: This is so for all right-handers and many left-handers, though not true for 15 percent of the left-handed, who are wired in the opposite fashion, so that a left-sided stroke is devastating in the way I recount here. At least that is the dogma. In my experience, though, left-handers do not have quite the same experience, but a more fluid, less rigid dichotomization of their skills and disabilities.

  Page 292. Dr. Dan had not added any new medications to her regime: To be specific: Dr. Dan first increased her Haldol and oxycodone, then added Lexapro, then increased her Haldol, started Depakote, then Ativan, increased the Depakote, and increased the Haldol. For a similar story about the development of serotonin syndrome, see Ladan Zand, Scott J. Hoffman, and Mark A. Nyman, “74-Year-Old Woman with New-Onset Myoclonus,” Mayo Clinic Proceedings 85(10) (2010): 955–58.

  Page 295. Dr. Stein had already given Mr. Conley an additional ten million dollars: I was given a hard copy of the plans for the “LHH Transition Budget: Consolidated Five Week Move—April 2010,” by someone who wishes to remain anonymous. The paper is not signed, but it is dated August 2008, and it documents the additional meeting.

  Page 296. The medical staff’s budget of 2.5 million dollars and the hospital’s budget of 170 million dollars: The various budgets were not easy to discover, and the actual costs of, say, the medical staff, or the hospital, were even harder to find. The best source I found is: www.sfdph.org/dph/files/lagunahondadocs. The minutes of the Health Commission are sometimes useful; they are at www.sfdph.org/dph/files/hc/hcmins. The minutes of the Laguna Honda Hospital Joint Conference Committee are also informative: see www.sfdph.org/dph/files/hc/jcc/lhh/minutes. By July 2008 the hospital was down to 903 patients and 16 full-time equivalent physicians. By May 14, 2008, Clarendon Hall was empty of patients.

  Page 296. The Department of Justice had accepted the Chambers settlement…. It still had two additional demands, however: Actually the settlement was confusing. There were, it seems, two separate documents. The first was a Side Letter from the US Department of Justice, dated May 23, 2008, that I saw only in hard copy. Somewhat later there was the “Settlement Agreement between the United States Department of Justice and the City and County of San Francisco regarding the Laguna Honda Hospital and Rehabilitation Center,” which was easy to find at the DOJ website. It demanded that there be fundamental changes to the hospital, in terms of its structure, function, and mission. For instance, the new Laguna Honda would “emphasize a continuum of care model” (1) by expanding its rehabilitation service, and it would “introduce as much flexibility as possible into existing and ongoing construction efforts at Laguna Honda so as to maximize the adaptability of use from SNF services to other integrated services going forward” (4). This sentence was interpreted by many to mean the eventual transformation of Laguna Honda from hospital to rehabilitation facility. Other demands were that “Every individual will be team evaluated, based upon his need and ability, not on the availability of services nor on the disability of the patient” (4); that efforts at discharge “shall continue even after an individual expresses initial opposition to certain specific placement proposals … regardless of the … family” (6); “Homeless patients with nursing needs will be kept out of Laguna Honda” (11); and “The city shall implement the Health Management Associates report” (13). For the document, see www.justice.gov/crt/about/spl/documents/​laguna.honda_hosp_setagree_6_13_08.pdf.

  Page 309. It would be so easy to just shock that ventricular tachycardia back to life: Easy in a manner of speaking. About 20 percent of people survive pulseless ventricular tachycardia, though many fewer actually survive to discharge from the hospital. For some statistics, see Mickey S. Eisenberg, MD, PhD, and Bruce M. Psaty, MD, PhD, “Cardiopulmonary Resuscitation: Celebration and Challenges,” JAMA 304(1) (July 7, 2010): 87.

  Page 310. Hildegard’s lines about dying came into my mind: “For this color in the knees lying on top of the skin is the fiery breath of the life of the anima, because the anima in man is showing that his vitality is outside his body and weakness is inside and stands as if uncertain; like a person who stands at a doorway uncertain whether to stay or leave.” “Rubeus enim color iste in genis super cutem iacens igneum spiramen uite anime est, quoniam anima in homine illo uim suam extra corpus suum demonstrat et se in corpore debilem et incertam ostendit, uelut homo, qui interdum ad ianuam domus sue procedit, cum de ea egressurus est.” Laurence Moulinier, Beate Hildegardis Cause et Cure (Berlin: Rarissima mediaevalia, 2003), p. 270: lines 7–11. For those readers of Classical Latin: In the Middle Ages, there was no j or v; i and u were used instead. Also, the ae ending dropped out, and e was used instead.

  Page 310. I had a different interpretation of DNR: The story of cardiopulmonary resuscitation and its mirror twin, Do Not Resuscitate, is complicated; for some background and clinical correlation, see Victoria Sweet, “Thy Will Be Done,” Health Affairs 26 (2007): 825–30, and Victoria Sweet, “Code Pearl,” Health Affairs 27 (2008): 216–20. In response to the poor outcome of resuscitation and the futile use of resuscitive measures in the terminally ill and the very old, a four-page form known as the POLST is now mandated in many states and medical trainees are now required to get advance life directives on everyone they admit. This is tedious, and the pendulum, therefore, has begun to shift the other way, with less being done than is, perhaps, indicated. For a provocative essay on this, see Boris Veysman, “Shock Me, Tube Me, Line Me,” Health Affairs 29(2) (February 2010): 324–326.

  CHAPTER TWELVE: THE SPIRIT OF GOD’S HOTEL

  Page 316. Two weeks later, Sister Miriam resigned: For her resignation letter, see www.westsideobserver.com/pdfs/nov080bsview.pdf. For her thoughts on Clarendon Hall, see Sister Miriam Walsh, “Farewell to Laguna Honda’s Clarendon Hall,” West of Twin Peaks Observer, April 2008, at www.stoplhhdownsize.com/Media08-04_Observer1.html. For a short biograp
hy, see “Laguna Honda’s Torchbearer, Sister Miriam Walsh,” by Patrick Monette-Shaw, www.westsideobserver.com/pdfs/feb10e-mail(5).pdf. I have a lot of stories about Sister Miriam. I particularly liked that she kept a little box outside her office with scraps of paper on which were Xeroxed a list of people you might want her to pray for. You could check “mother, father, son, daughter, or the souls in Purgatory who have no one to pray for them.”

  Page 319. Marketing had presented its branding campaign: Much was disconcerting about these new marketing efforts. For instance, on the Laguna Honda website, many of the photos of “patients” were not actual Laguna Honda patients but photos of other patients walking in other gardens of other hospitals.

  Page 324. The next week she sent around a revised organization chart: The organization chart can be found online; although mislabeled 2005, it is dated April 2, 2009; see www.docstoc.com/docs/9216131/lhh-Org-Chart-2005. For a biography of Mr. Conley and a description of his memorial service, as well as the announcement of Dr. Stein’s appointment of Mirene, see The Laguna Honda Grapevine, issue 22, March 23, 2009.

  Page 324. Mirene’s main ally in her new job was Adrian Serf: Dr. Romero reported an instance when Mr. Serf went to a bedside to convince a patient not to go back to the County Hospital, in spite of Dr. Romero’s orders to do so. From her “Statement of Concern—Patient Rights and Physician Responsibilities,” November 17, 2009 (personal communication).

  Page 325. The final straw was the Ja Report: For the Ja Report, see “Evaluation and Assessment of Laguna Honda Hospital Behavioral Care and Service Access: A Final Report,” www.victoriasweet.com/docs. It simply put into its recommendations the unpublished document “Building a National Center of Excellence in Long-Term Care and Rehabilitation,” LH Organizational Development Initiative Document (February 25, 2009) (personal copy). For Dr. Kay and Dr. Romero’s report, see “The Ja Report, A Job Half Done: A Critical Analysis” at www.stoplhhdownsize.com/​A_Critical_Analysis_of_the_Ja_and_Associates_Report_on_LHH_Services.pdf. Another critique was written by the city’s long-term care ombudsman, Benson Nadell, “Thoughts on Davis Ja Report: The Move Away from a Medical Model of Care,” October 6, 2009, www.stoplhhdownsize.com/Thoughts_on_Davis_Ja_Report.pdf.