Tag Archives: ideal

by

An ideal death

Death is quotidian, isn’t it?

There is a movement to make death more ideal. I agree that we should talk more about death and find out what people want, but ideal is complex. The VA did a survey and found three ideal deaths. Which is your ideal?

  1. The Hallmark Death. In hospice, surrounded by family and friends, making peace with everyone, visitors from all over. My mother died of ovarian cancer. We had a hospital bed and a baby monitor and when she was awake, she would say, “I am ready to be entertained.” It lasted for 6 weeks and my grandmothers bones rose out of her face as her weight dropped. I was so tired by the end that I couldn’t see straight. She did not want us to cry, so my sister and I did not cry. Afterwards I wished that I had cried.
  2. No warning, sudden death. Take me, in my sleep, or suddenly, with little or no warning. The heart is the number one cause of death. My father went this way, in his home. I was the one who found him, though I’d expected it for over a year. He was a bit of a hermit and had horrible emphysema, was on oxygen and steroids, but he stayed at home. That’s what he wanted and I did not fight it. It was not much fun finding him.
  3. Fight every step. There are some people who remain full code, who have end stage cancer and want dialysis, who will not give in. My sister was in this category. She was a truly amazing fighter and refused hospice until the last week. This can be about believing that one can continue to hope for a miracle or it can be about social justice or about a promise to one’s family. Some families have said, if father had been able to access care earlier, he wouldn’t be dying, so he wants everything done. I can understand all of those feelings.

So which would be your ideal? Ideally we would talk to our parents and our children and explore these different ideals. I did that with people in clinic. There are interesting openings. A patient would say, “I don’t want to die of cancer.” I would say, “How do you want to die? What is your ideal?” They would be surprised and I would explain the three different scenarios above. “Put in your order, though we do not have any control.” I would say.

We do not have control. I did prenatal care and deliveries for 19 years and didn’t have control there. I always preferred to intervene as little as possible and only if I had to for mother or baby’s health. Once our surgeon went to take out an appendix and it turned out to be something else, so took three hours. I had called a cesarean section, but had to wait. The baby had a fast heart rate and it rose in those three hours. We finally did the c-section and the baby promptly looked completely fine. I have no idea why the heart rate rose from 140 to 180. We were all hugely relieved. Sometimes the cause was obvious: a short umbilical cord or a cord wrapped four times around the neck, but sometimes the cause is a complete mystery.

I talked to a person yesterday who has a frail 90 year old in their life. They said something about keeping them from dying. I said, “Well, they are going to die eventually.” Then I thought, I wonder if they have had the discussion: what is your ideal? Do everything, which may mean being in a hospital? Hospice? At home? And I sometimes see families fight, because siblings have different ideals and may not even be aware of it.

Blessings.

For the Ragtag Daily Prompt: quotidian.

I took the photograph of the neighbor’s flowers while I was walking the cats in the dark. I like it.

by

Diagnosis is only half the job

In clinic I have two jobs.

The first job is to diagnose. Chief complaint, history of present illness, past medical history, allergies, review of systems, medications (and vitamins and supplements and herbs and any pills or concentrated substances), social history including addictive substance use, family history, physical exam. What is my diagnosis? A clinical portrait of the patient.

The second job is to communicate and negotiate. I have to get a snapshot of the person’s medical belief system, their past experience with MDs, their trust or lack of trust, whether they are willing to take a prescription medicine. I have to try to understand their world view at this visit, at this moment in time. And it’s not static and may change before I see them again. If I can understand the person well enough to communicate with respect, with concern, with understanding, then we may be able to negotiate a treatment.

In clinic the other day I had a new patient who said, “I am not going to be pushed to take prescription medicine.” I responded, “That’s fine. I am not going to be pushed to do medical testing that I think is inappropriate, either.” She actually laughed and said, “Ok. That’s fair.” This is a patient who is coming from alternative treatment but wants medicare to cover her tests. After the visit she called and said that her provider wants a certain test before they feel comfortable proceeding with a therapy. I responded that I need a note and an explanation of the planned therapy before I will order the test. (Honestly, it’s an increasing trend that I get calls from patients with messages like “My orthopedist wants you to get my back MRI prior authorized.” and “My physical therapist wants my hand xrayed.” Our new office policy is: the provider has to communicate themselves, not via the patient. Also, it ain’t always so….)

I had patient once in the emergency room who said, “I have an antennae in my tooth. Get it out.” Her roommate nodded, looking terrified. This was after a fairly confusing complaint of tooth pain. I needed to think about an approach. I said, “I need to check on another patient. I will return.” I left the room in the emergency room and considered approaches. I went back in and said, “I am not a dentist. I can’t take out the tooth. BUT I can call a doctor to help with the sounds that you are hearing until we can deal with the tooth. The doctor is a psychiatrist.”

“Ok. Call them.” said the patient. The roommate practically collapsed with relief. Psychiatry said, yes, looks like psychosis and we have a safety contract and she will come in Monday. People HAVE actually had metal in their mouth that picked up radio sounds, but psychosis is much more common. Also, if you can say the station call sign that is a lot different than voices that are telling you to harm yourself.

I thought about my approach carefully. I did not want to argue about the tooth. I wanted her to agree to talk to psychiatry. So I told the truth: I can’t fix the tooth. It’s Saturday night. Here is what I can do. I never said, hey, I don’t think it’s the tooth, I think it may be a psychotic break. She may have known that it was not the tooth but been too terrified or too disorganized to tell me. And there was a small chance that in fact, it WAS the tooth.

It is not worth trying to “fix” or change someone’s world view. If they trust their naturopath more than me, that is ok. But it’s a negotiation: I am a MD and I will do treatments that I think are appropriate and safe and I may or may not agree with the naturopath or chiropractor or physical therapist or accupuncturist or shaman. But the goal in the end is NOT for me to be correct: it is to help the patient. Half the therapy is respect and trust and hope. And kindness.

The biggest problem with ten minute visits and the hamster wheel of present day medicine in the US is that the second job is often not possible. Complex diagnoses are missed or patients leave feeling unheard, not respected and frustrated. Time to make the connection and to understand is very important and is half the job. Physicians and patients are frustrated and it is only getting worse.

 

The photograph is my daughter and her wonderful violin/viola teacher, right before my daughter played for a music competition.