I can't even imagine what it's like to be a lay person again with regards to adult medicine. Doctors see things through doctor eyes. Patients and families see things through patient and family eyes. Quite often the two visions are not congruent. And often times, the situation is not helped by partially trained pseudo lay people telling families information that is simply not correct. Let me give you an example of a common patient of mine. This is not an exaggeration.
An 87 year old man transferred for direct admission from a local nursing home.
What I see:
CAD with a hx of CABG (coronary artery disease with a history of coronary artery bypass grafting)
AF (atrial fibrillation)
HTN, uncontrolled (hypertension)
COPD (chronic obstructive pulmonary disease)
DMII (diabetes mellitus type two)
CKD stage IV (chronic kidney disease stage four) baseline glomerular filtration rate of 18
Pacer
PVD (peripheral vascular disease)
GERD (gastroesophageal reflux disease)
OA (osteoarthritis)
Obesity
What the family sees:
Dad/Grandpa was just put into the nursing home a few weeks ago. He's been falling. He tore up his leg a few weeks prior. He just seems so weak. Mom couldn't take care of him. It's only temporary. We are fixing things up at the house so when he comes back it will be safer. This is only temporary. He's been using his walker pretty heavily for the last 6 months. He doesn't move much anymore regardless.
Patient gets admitted with ARF (acute renal failure). Bun of 187 (normal 20). Creatinine of 9 (normal 1).
What I see:
What are his baseline normal numbers? What is the cause of acute decompensation. Prerenal? Renal? Post-obstructive? Is this fixable? Are there any urgent dialysis needs? I need to avoid dialysis at all costs. Why does he have gross blood in his catheter? Was it traumatically placed? Does he have hydronephrosis? What is his volume status. Is he dry or wet? What is his oxygen status? Is he at risk for acute decompensation? What are his electrolytes? Na? K? Hgb? Is he infected? Is his heart stressed? What is his EF?
After reviewing the chart, all the data, labs, I make a determination that the patient does not need any urgent kidney dialysis. My hope is to hydrate him. His catheter has relieved his post obstructive urinary retention caused by an enlarged prostate and he will hopefully get him back to his baseline stage IV kidney disease. The last thing in the world I want for him is to get started on dialysis. It will be his death sentence. I have seen too many people just like him live out their lives in misery on dialysis. Dialysis in his age and his condition will be miserable and painful and full of complications.
What the family sees
The family is expecting dad/grandpa to be started on kidney dialysis tonight. At two a.m. Why? Because the paramedic told them that dad needs dialysis. The family is expecting dialysis to make grandpa better. They are expecting troops of doctors to come barging through those patient doors in an emergency, life or death situation. By now,the paramedic is gone and I'm left explaining why I am unimpressed with the urgency of the situation. There won't be anyone but me seeing dad tonight. I'm sorry to disappoint you. You're stuck with me for the night. So anticlimactic it would seem. I have no idea what the paramedic told them. But emergency dialysis was not the right answer.
The same thing happens with nurses and between doctors as well. Nurses tell patients things that simply aren't true. Doctors do as well. One doctor says one thing. Another says another. They often seem to contradict each other. I see this often when polyconsultation is established. Five doctors each telling the patient things that only they can understand, trying to paint a big picture and failing miserably when that picture doesn't overlap with what the other doc said twenty minutes ago. The patient is left holding the bag of confusion.
DNR: What I see
When I explain to the patient that having that high a level of disease burden would cause incredible misery and pain should they want me to do CPR, they will often tell me they don't want to be hooked up to all those tubes and machines. I tell them that is the right decision, a decision I would make for myself if I was in their condition. I tell them I have seen far too much pain and suffering by performing CPR on end stage medical conditions.
DNR: What the family sees.
Why are you convincing dad to die? This was an actual response once. Often times they are horrified that I am suggesting not to resuscitate dad. I tell them very clearly that not resuscitating him is the right decision for somebody with his burden of disease. I tell them that the heart would stop for a reason, and I can't fix it.
It still amazes me how some families are so in tune with reality and some have no clue about reality. 87 year olds with multiple chronic medical conditions do not start dialysis and get better and go home. They do not live out their lives in painless bliss. Some have never been explained the current reality. Some bounce from doctor to doctor with ignorance, believing there is an end of the tunnel.
I'm here to tell you, when you have heavy burden of disease, there is no end of the tunnel. It will be perpetual. You will get to know hospitalists well. You are the 5% of the population that spends 50% of all health care dollars. You will not be getting better to go home. Your new home is Happy's Hospital. So you better start liking me.
Internal medicine is great when it exists only in books, however, when you translate it to actual practice, it is no fun. Glad I don't do it anymore.
ReplyDeleteExcellent post! What you say rings true. With two elderly parents who have been hospitalized 2-3 times each in the last year, I know the drill. I also know the realities of family expectations and the feeling that all we do is put a band-aid on a gushing wound, creating confusion with so many opinions. I wish my colleagues would think before they speak sometimes but we tend to feel that patients/families are asking for our thoughts and advice much of which is misguided speculation that comes from NOT seeing the whole picture. I admire you hospitalists and what you face every day, walking on the ward. I could not do my work without you. You're right about this guy's renal problems BTW. Best to you!
ReplyDeleteIt is true how differently people see things. I wanted to do a little trial about 8 years ago involving women's perception of their breast cancer risks. I wanted each woman to write down the percentage chance that they would develop breast cancer in 10 years. Then I would lecture on breast cancer and have them re-evaluate their answers. Then I wanted to use the Gail Model to calculate their approximate risk and see how the three values correlated. Unfortunately, I never got around to it but I think it wold be interesting.
ReplyDeleteGreat article...FYI...Chicago Sun Times here...
ReplyDeletehttp://www.suntimes.com/lifestyles/travel/blogentries/index.html?bbPostId=BAfMYODD5A1mB4i22hiR9pHlCz3HSp2rPHIreBDjAAmAf2P7q
While I agree with the main sentiment in this post, I am bothered by this statement "Their years of smoking, immobility, obesity, alcohol abuse and noncompliance catch up". Hello? The man is 84, a lot of people who do everything right - don't smoke, stay slim, are compliant - don't live that long. Are you implying that those of us who don't smoke, live healthy lifestyle and listen to our doctors are all going to live forever or just die "healthy"?
ReplyDeleteDo you have some study to show that people who do everything "right" live forever? Or that they don't get sick at the age of 70 or 80 and just die painlessly in their sleep?
Don't most people get sick when they get older, often with multiple conditions? Don't people who live healthy lifestyle, don't smoke, still get sick if they live long enough? Sure they may get heart disease later, but most will still do.
Guess what. My 73-year old mother just got diagnosed with lung cancer. Has never smoked, her husband (my father) has never smoked, her parents never smoked. Yes, she has heart disease as well. No diabetes, although I am sure my mother would chose it over lung cancer any day.
Doing "everything right" may reduce certain conditions, may postpone them, but it certainly doesn't guarantee it will not happen. This blame-the-victim statement you made is just plain irresponsible, not to mention stupid (unless you can show a study that people who do everything "right" are guaranteed quick and painless death).
BTW - my mother has a living will with DNR, everyone in my family does. She has also already said that if time comes and she can only survive with a breathing tube, she doesn't want it.
"Has never smoked, her husband (my father) has never smoked, her parents never smoked."
ReplyDeleteOh, and her child doesn't smoke either. Totally non-smoking (even very anti-smoking) family. Not even second cousins... Reducing risk doesn't mean eliminating risk. As a doctor you should know it.