(no subject)
Yesterday during sit-down rounds we were discussing a new holding note admitted overnight. It was a woman who has been admitted 5 other times in 2007 alone. She has cor pulmonale secondary to pulmonary hypertension because of her refusal to use C-Pap for her severe sleep apnea. While trying to examine her that morning the intern had given up because of her non-compliance with the history and squeals of pain at even the lightest touch anywhere on her body. As it turned out the attending had admitted her to other services numerous times in the past and was very familiar with her medical history and social setting which was rather significant for the fact that she had lost all mobility at home and would frequently have bowel movements in bed causing her 86 year old husband with little to no lower extremity function to crawl across the floor and help wash her. More out of frustration by her frequent admissions in the face of continuous non-compliance the intern suggested that hospice be brought up at the bedside and it was determined that this would be done.
When we arrived at the bedside our patient was almost as cranky as the intern had described her. She did squeal in pain at even the lightest touch. Her upper extremities and face looked uncomfortably edematous and her voice was a surprising barky; squeaky combination. The attending tried to explain to her the severity of her illness and unlikely chance at a better quality of life if she didn't comply with the C-pap. As she heard the phrase "poor prognosis" she asked almost hopefully "Am I going to die?” When told that yes this was likely she responded "how long?" After hearing that it would probably be within the next six months she said "I’d better call my husband." The tone of her voice sounded to me like she'd been relieved to hear this but felt that it might be difficult for her husband to understand. She seemed appropriate in her ability to digest the material; the gravity of what it mean; but also comfortable with being told this; as if her quality of life didn't hold many enticements to fighting for prolonged survival. She was asked if she would like us to call hospice; and yes she did. However when asked if she understood what was going in on and why she was going to die she simply responded "I'm all swolled up." But why is that the team wanted to know. "Because I got too much fluid". Why do you have to much fluid? "Can't you see I'm all swolled up? and round and round it went.
Once we had left the room the attending said we needed a psych consult as he felt she lacked insight into the gravity of this decision and should be evaluated for major depression impeding her decision making ability. What surprised me was how annoyed I was by this reasoning. Understandably this is a big decision and talking it over with a clinical psychologist might be beneficial. However to get a psychiatry consult for this woman who really displayed relief rather than "anhedonia" at the possibility of not being put through the constant re-admissions to gain an inch of ground only to lose a foot when sent back to the nursing home seemed to be more for the comfort of the primary team than having any actual benefit for the patient. It reminded me of one of our ethics lectures last year regarding informed consent. Apparently it's quite common for physicians to question a patient's decision making capacity when the patient decides something contrary to what the physician thinks is best. This seems rather arrogant of us.
Even more frustrating in this scenario was the rationale behind the call for a psych consult. It was felt that she "lacked insight" into her disease process. I was a witness to the explanation she received regarding her disease and it is not surprising she lacked insight as the explanation was loaded with medical jargon and rattled off at a surprising rate.
I was fortunate enough to volunteer with hospice prior to starting medical school and so perhaps my view on the approach to death has been formed by that experience. This patient; despite not having a "terminal" diagnosis; does not have a good prognosis for recovery or even improvement. To her C-pap is a frightening experience that causes claustrophobia and it is not worth it to her to go through that even if that is what is needed to improve her cardiopulmonary function. Who are we to question that?
The patient was not at all bothered by the psych consult; although the psych resident thought it a bit ridiculous. There were no psych issues raised and so our care turned to a palliative approach. The patient and her husband were chatting quietly the next time we entered the room and seemed at peace with the course things had taken and I was grateful that this was the case, even if she was still unable to tell us what was causing her profound edema.
When we arrived at the bedside our patient was almost as cranky as the intern had described her. She did squeal in pain at even the lightest touch. Her upper extremities and face looked uncomfortably edematous and her voice was a surprising barky; squeaky combination. The attending tried to explain to her the severity of her illness and unlikely chance at a better quality of life if she didn't comply with the C-pap. As she heard the phrase "poor prognosis" she asked almost hopefully "Am I going to die?” When told that yes this was likely she responded "how long?" After hearing that it would probably be within the next six months she said "I’d better call my husband." The tone of her voice sounded to me like she'd been relieved to hear this but felt that it might be difficult for her husband to understand. She seemed appropriate in her ability to digest the material; the gravity of what it mean; but also comfortable with being told this; as if her quality of life didn't hold many enticements to fighting for prolonged survival. She was asked if she would like us to call hospice; and yes she did. However when asked if she understood what was going in on and why she was going to die she simply responded "I'm all swolled up." But why is that the team wanted to know. "Because I got too much fluid". Why do you have to much fluid? "Can't you see I'm all swolled up? and round and round it went.
Once we had left the room the attending said we needed a psych consult as he felt she lacked insight into the gravity of this decision and should be evaluated for major depression impeding her decision making ability. What surprised me was how annoyed I was by this reasoning. Understandably this is a big decision and talking it over with a clinical psychologist might be beneficial. However to get a psychiatry consult for this woman who really displayed relief rather than "anhedonia" at the possibility of not being put through the constant re-admissions to gain an inch of ground only to lose a foot when sent back to the nursing home seemed to be more for the comfort of the primary team than having any actual benefit for the patient. It reminded me of one of our ethics lectures last year regarding informed consent. Apparently it's quite common for physicians to question a patient's decision making capacity when the patient decides something contrary to what the physician thinks is best. This seems rather arrogant of us.
Even more frustrating in this scenario was the rationale behind the call for a psych consult. It was felt that she "lacked insight" into her disease process. I was a witness to the explanation she received regarding her disease and it is not surprising she lacked insight as the explanation was loaded with medical jargon and rattled off at a surprising rate.
I was fortunate enough to volunteer with hospice prior to starting medical school and so perhaps my view on the approach to death has been formed by that experience. This patient; despite not having a "terminal" diagnosis; does not have a good prognosis for recovery or even improvement. To her C-pap is a frightening experience that causes claustrophobia and it is not worth it to her to go through that even if that is what is needed to improve her cardiopulmonary function. Who are we to question that?
The patient was not at all bothered by the psych consult; although the psych resident thought it a bit ridiculous. There were no psych issues raised and so our care turned to a palliative approach. The patient and her husband were chatting quietly the next time we entered the room and seemed at peace with the course things had taken and I was grateful that this was the case, even if she was still unable to tell us what was causing her profound edema.