We begin with a lecture: “How do people die?” A 55-year-old physician who runs a weekly geriatrics clinic explains why he became a geriatrician. “My father died terribly. He was in months of pain and misery during cancer treatment. At the end of his life he told me he regretted getting treatment. It is my opinion that his doctors did not present him with realistic expectations.”
He draws a graph of function versus time on the whiteboard, each line representing a single human life. “Seven percent of people die a sudden death, meaning they are highly functioning and die out of the blue.” He draws a horizontal line high on the y-axis until it plummets when the patient dies. “These are the massive heart attacks causing cardiac arrest, the motorcycle accidents with immediate death.” He then draws a downward sloping line. “22 percent of people die of terminal illness — a long steady decline. 16 percent die of organ failure where you have ups and downs, trending down for a long time.” He continues, “So what’s left? 47 percent die of frailty. These are people who are low functioning for a long time.” In summary: “We need to think if we want to flog granny with chemotherapy and LVAD [left ventricular assist device for heart failure] just to set her up for frailty.”
His clinic reviews medications to prevent falls and unnecessary hospitalizations, evaluates prognoses for dementia and advanced chronic diseases, and discusses goals of care, including independence. “One of the most challenging discussions with the elderly is when to stop driving. Remember that the patient never voluntarily gives up driving. It signifies so much for them. A lot of time driving is essential to care for their spouse.” He emphasizes, “It is the doctor’s job to discuss when a patient should stop driving. I remember one time a patient was referred to me and he lived a few blocks down the road from me. He could barely dress himself, but was driving every day to the store. ‘Would you be okay with your son or daughter driving on the same road?’ I don’t understand how physicians are supposed to have these complex discussions with patients with all the EMR [electronic medical record] demands and time constraints, but we have to find a way.” He adds, “A good rule of thumb: if a patient cannot perform the trail-finding test on the MOCA, the patient does not have enough executive functioning and information processing capability to drive.”
“Our clinic has a three-month back up right now. We’re still working off the backlog that develops during Thanksgiving and Christmas. The family flies in for the holidays only to find that mom has not bathed in months. They say, ‘But she sounded okay on the phone.'”
Farmer Fiona: “I agree with what he is saying about asking patients how they want to die, and that patients are vulnerable to believing best-picture prognosis. But he doesn’t say what we should do to manage unfortunate events. Should patients not undergo catheterization after a heart attack? Not get amputated after a gangrenous diabetic infection? Maybe he wants us to tell patients to keep smoking so they die of a massive heart attack, instead of the long fragility of dementia or pancreatic cancer?” Southern Steve: “Is it worth risking getting dementia to live to 100?”
After lecture, Fiona and I drive 10 minutes to the hospice clinic where we get a tour from a 56-year-old volunteer office manager. He explains: “Hospice sprang up as community volunteer organizations. We used to be able to take patients on fishing trips, meals, shopping. We can’t do that anymore because of the liability of driving patients and all the paperwork involved with insurance. The volunteer tradition is going away, but five percent of a hospice workforce must still be volunteer to qualify for Medicare reimbursement.”
I follow a 48-year-old hospice nurse around the city for three home visits. My first patient (a 35-minute drive away): is an 89-year-old end-stage dementia patient. Before we go in, the nurse explains that family members are “really struggling giving medications (oxycodone and benzodiazepines) because they are afraid of killing her.” She explains to the son, daughter-in-law, two granddaughters, and great-grandson that the doses of pain medications are so low she will be fine: “She needs these medications. We don’t want her to suffer.”
[Editor: The U.S. has 5 percent of the world’s population and consumes 80 percent of the prescription opioids.]
After spending 10 minutes at bedside, including a short prayer led by the hospice chaplain, our patient is agitated. We go to an empty bedroom for a family meeting. Everyone starts crying. The son: “I am not ready to let her go. I freak out about giving her medications if they are going to hasten her death.” Hospice nurse: “She is ready to go. You have to accept that and prepare yourself.”
Our next patient with advanced COPD and dementia lives in an upscale continuing care retirement community home. She has a 24-hour home aide who has dressed her in stylish clothing, arranged her hair, and applied makeup. She takes shallow breaths as she stares blankly into space, not acknowledging the two strangers in her apartment. We talk with the 38-year-old home health aide, a relative of family friends who has been taking care of her for two months. The hospice nurse: “You can tell she is going to die soon. She’s ready. It’ll be tonight I think.” She calls the family’s relatives to come to the apartment. (Our patient died three hours later, with her family at bedside.)
Our last stop: an 86-year-old bedbound patient with congestive heart failure living in a beautiful six-bedroom house. A professional 28-year-old home health aide takes care of him (and the bulldog who greets us at the door) five days per week and a neighbor’s failure-to-launch 34-year-old son handles the weekends. We turn him over to look for bedsores; the home aide has done a very good job. When was the last time you pooped? The aide responds that it has been at least six days. The nurse looks at me. Enema time. We roll him over to one side, and perform an enema. He has so much impacted stool we do two. The enema took about twenty minutes. The nurse was surprised that I helped throughout the enema. “Most doctors walk out the door as soon as the thought of an enema pops up.”
I drive back to the hospice clinic for afternoon handoff with Farmer Fiona. Nurses and the palliative care physician are talking about overnight drama between the hospitalist service and palliative care team regarding a terminal cancer patient experiencing poorly controlled pain. “The family did everything right and called the hospice instead of going to the ED. But this hospice does not have flex weekend home visits.” The family brought the patient to the ED, and the medicine service requested the palliative team admit the patient. The palliative care physician: “I told them that we are not admitting the patient. This is a disposition issue that their social workers can manage. We are not in-charge of every hospice patient,” she noted. “We’d be happy to consult on the patient in the morning to provide pain control recommendations, but we are not admitting to our unit. We have limited resources.” (Last week on their service, we sat idle for half the time, sipping specialized coffee drinks made by a volunteer and discussing must-read medical books..)
Thursday morning is a normal day with Doctor Dunker at my family medicine clinic. We had a monthly potluck office lunch featuring homemade apple turnovers. Staffers are comparing their role-specific Bingo cards. For example, Doctor Dunker has a square: “Patient asks for antibiotics before patient is seen by doctor.” The office secretary: “Patient no shows appointment within 24 hours of scheduling.”
I depart after lunch for an afternoon at the travel clinic. The travel clinic, staffed by an infectious disease doctor, is meant as a community resource for individuals traveling for extended periods of time to remote destinations, e.g., six-month mission in Africa or the Amazon. Instead, all four of our patients are going on cruises with limited exposure to dangerous disease beyond an afternoon in Cartagena, Colombia. There is no attempt to hide from the patients that we are primarily looking up information on the CDC web site.
[Editor: Cartagena was where agents accompanying President Obama to the Summit of the Americas used government credit cards for an epic party. See “US Secret Service Cartagena scandal ‘involved 20 women'” (BBC).]
Friday afternoon, we have a class meeting about prevention in primary care. The lecturer, a retired hippie family doctor, discusses the “Pay-for-Performance” era. He reviews a “landmark study” finding that the highest performing practices according to metrics in the UK had no change in patient outcomes compared to poor performing practices. “Despite this evidence, we will see more and more oversight by administration evaluating performance metrics. We’ll soon be telling patients, ‘I need you to get a mammogram, flu shot, etc. because it will improve my clinic performance.'”
[Editor: We learned the same thing in our data-driven medicine class at Harvard Medical School. Except for generating headlines, preventive medicine is of limited value. Popular screening tests, such as mammograms and pap smears, generate so many false positives that patients on balance may be worse off. Flu shots for adults are only weakly correlated with being diagnosed with flu.]
He continued: “One challenge for performance metrics is they address challenges of the past or are out of touch with reality. For example, hospitals get graded on how quickly we start antibiotics for sepsis and pneumonia — the proportion started within 8 hours. This metric is based on studies in the 1990s which showed early administration improved outcomes in sepsis. However, this was on a totally different patient population and different bugs because this was in a day before the pneumonia vaccine existed. There is no evidence administration within 8 hours is beneficial, and instead might cause unnecessary antibiotic administration. You all see that so much, antibiotics are started in the ED for a few hours and then discontinued by medicine service the next day.”
Statistics for the week… Study: 7 hours. Sleep: 7 hours/night; Fun: 1 night. Lanky Luke, Sarcastic Samantha, Mischievous Mary, Geezer George, Buff Bri, Jane, and I attend a free concert downtown.
The rest of the book: http://fifthchance.com/MedicalSchool2020
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