Dr. Cranquis' Mumbled Gripes

aspiringdoctors:

New York Times op-ed article.

“…As the aging baby boom generation places unprecedented demands on the health care system, there is little ordinary citizens can do — witness the tortuous arguments in the Supreme Court this week over the constitutionality of the Affordable Care Act — to influence either the cost or the quality of the treatment they receive. However, end-of-life planning is one of the few actions within the power of individuals who wish to help themselves and their society. Too few Americans are shouldering this responsibility.

Of course many people want more aggressive treatment than my mother. And advance directives aren’t “death panels”; they can also be used to ensure the deployment of every tool of modern medicine. They can be changed or withdrawn at any time by a mentally competent person.

But public opinion polls consistently show that most Americans, like my mother, worry about too much rather than too little medical intervention. In a Pew Research Center poll released in 2006, only 22 percent said a doctor should always try to save a patient’s life, while 70 percent believed that patients should sometimes be allowed to die. More than half said they would tell their doctor to end treatment if they were in great pain with no hope of improvement.

Yet only 69 percent had discussed end-of-life care with a spouse; just 17 percent, or 40 percent of those over 65, had done so with their children. One-third of Americans had a living will and even fewer have taken the more legally enforceable measure of appointing a health care proxy to act on their behalf if they cannot act for themselves.

The latter omission is especially disturbing because by 2030, more than 8.5 million Americans will be over 85 — an age at which roughly half will suffer from Alzheimer’s disease or some other form of irreversible dementia. For many members of the baby boom generation — more likely to be divorced and childless than their parents — there may be no legal next of kin.

Without advance directives, even a loving child may be ignorant of her parent’s wishes. My mother remained conscious and in charge of her care until just a few days before she died, but like most women over 85, she was a widow. My younger brother died of pancreatic cancer two weeks before she did. It was an immense comfort to me, at a terrible time, to have no doubts about what she wanted.

My mother drew up her directives in the 1980s, when she was a volunteer in the critical care lounge of her local hospital. She once watched, appalled, as an adult daughter threw a coffeepot at her brother for suggesting that their comatose mother’s respirator be turned off. Because the siblings could not agree and the patient had no living will, she was kept hooked up to machines for another two weeks at a cost (then) of nearly $80,000 to Medicare and $20,000 to her family — even though her doctors agreed there was no hope…”

Doctor experiences first-hand the useful side of consulting Dr. Google.

This article reminds me of a situation when a patient’s primary care physician (PCP) and myself colluded to not tell a patient about a suspicious x-ray finding — for a little while.

Behind the Medic: The TSK of when Cranquis Paternalized a Patient.

I’d seen 50-something “Bob” in the urgent care, and he was in bad shape. As far as I could tell, his stomach pains and nausea were due to gastritis, secondary to a mixture of excess NSAID use for his chronic pain + his recent resumption of a heavy alcohol habit (He was back to drinking a fifth of vodka every night, after being sober for 3 months — “There’s so much stress in my life right now, doc. My mom and I have been fighting, and I couldn’t stay sober and deal with the stress.”). The only reason I did a chest xray as part of his workup was because his lung-sounds were suspicious for fluid around the lung bases (a possible secondary effect of “abdominal ascites,” fluid collecting in the abdomen after liver failure).

The labs and xrays looked ok for him to go home instead of being admitted to the hospital, and he was happy about this because he didn’t have health insurance and was already stressing about the cost of that day’s Urgent Care visit. But I arranged for him to see his PCP early next week, and admonished him to start cutting back on his alcohol in preparation for getting off the sauce again. He said all the right things: “I’ll go to AA tomorrow morning, my brother will drive me home and stay with me for a couple days,” but it was hard for me to take him seriously. After all, I’d felt the metal flask in his cargo-pants pocket while I was examining his stomach.

The radiologist’s report came in the next morning: “Chest film shows a small irregularly-shaped density in right lower lobe, concerning for soft-tissue malignancy vs overlying chest-wall abnormality, cannot rule out old rib fractures in this area.” 

Oh great. What am I supposed to do now? Follow my usual routine — call the patient, inform them of an irregular finding on the chest xray, and arrange for ASAP follow-up with their PCP? This would just give Bob even MORE stress, which would shoot down any attempts he might be currently making to cut back on the alcohol use.

When I spoke with his PCP about the situation, he agreed with my hesitancy: “Bob’s anxiety and alcoholism can’t handle this extra piece of stressful news right now. I’ll call and remind him to keep the appointment on Monday, and break the news to him then and order a chest CT.” I felt relieved that Bob’s PCP was going to take over and handle it, but I felt a little dishonest at not notifying the patient of his results myself immediately, as I usually do with any tests that I order. But there was more at stake here than just “being transparent and honest” and “upholding the patient’s autonomy.”

Were his PCP and I being paternalistic? Yeah, a bit — but I hope that it was in the best sense of “behaving as a father”: making a hard decision on his behalf, a decision which would protect him from carrying increased (and out-of-his-control) stress during a difficult moment in his life. Bob was hurting, and he was striving to hide the hurt in a way which was killing him. He couldn’t even turn to his mother for peace, since she was one of the major causes of his stress. What he really needed was a Father, but the best I could offer him was my own fatherly instinct.

(Note: The chest CT came out clean, but as of Bob’s most-recent visit with his PCP, he’s still drinking.)

ilovehotcoffee:

says: “One of several things could cause your symptoms.”
means: “I haven’t the foggiest idea what’s wrong with you.”

says: “Are you certain you haven’t had this before?”
means: “Because now you’ve got it again.”

says: “I’d like to run that last test over.”
means: “The lab lost your sample.”

says: “This prescription has a few side effects.”
means: “You may experience sudden hair growth on your palms.”

says: “Your insurance should cover most of this.”
means: “You’ll have to sell your house to cover the rest.”