Monday, November 8, 2010

More On Old Fashioned Internal Medicine-Discussing End Of Life Care

I spend a good deal of time talking and thinking about death. It's unavoidable. Not in a morbid or fearful way....more about how to bring my patients dignity and how to bring their families peace. It's something that I do not particularly enjoy...but I am good at it. I have many patients in their eighth and ninth decades, it comes with the territory.

The other day I was lost in thought as I entered the ICU. It was Saturday morning and the hospital was quiet. I was on my way to meet a patient and her four children to discuss whether to continue aggressive medical treatment or opt for comfort care. As I rounded the corner I ran into a surgeon colleague.

I say colleague loosely because we had only worked together once on a single patient. The last time I had seen him was in that very same ICU. Except at that time we were in a conference room, having an end of life discussion with a large family. Around twenty of us. Husband and children, grandchildren and medical professionals. The ICU attending and nursing staff were there. And of course....the surgeon sat quietly next to me.

I cleared my throat and began my talk. First I summarized to the family and staff the patients medical course...using non medical language. Then I described her current prognosis and the different treatment options including aggressive treatment verse comfort care. Lastly I exhorted the family to picture their loved one a year ago. If she could see what was happening to herself now what would she want us to do for her?

Next the surgeon stood up to talk. Although an accomplished pancreatic surgeon known and respected by many....he was gentle and nonintimadating now. He who so deftly maneuvered scalpel and forceps was just as gifted in oratory. Clearly caring and humble...he described what had and hadn't happened right. He layed out the risks and benefits to the family and gave a pause for them to decide.

After many minutes of discussion the family chose comfort care and hospice was called. The patient expired a few hours later.

The surgeon and I convened shortly after the meeting. He was clearly shaken. His grace and easy communication obviously a crutch to hide his inner turmoil. He confided that he had never lost a patient like this before.

As I stumbled upon him again on this quiet Saturday morning I felt a strong emotional connection. It had been pure chance that we had not worked with each other again. He asked about the patients family and how they were doing.

As I think about this encounter it dawns on me that the surgeon really didn't deal with death much. Not the way I do. He hadn't run multiple family meetings each month. He hadn't watched over the years as patients decline with age and are ravaged by chronic disease. He hadn't formed the intellectual and emotional connections with families that only come after years and the roller coaster ride of health and sickness that each of us eventually endures.

And that's what I think Internal Medicine doctors (as well as family practice, palliative care, etc) do well. Especially those that follow during hospitalization. We deal with death...not in abstract terms but in concrete everyday decision making. We are there to guide families at their time of need. This guidance often comes with an intimate knowledge of the patient and family garnered over many years of contact.

I have great fear that as the migration away from Internal Medicine continues we will lose some of this expertise. And it will be our patients....our patients that will suffer the most.


deb said...

Very thoughtful post. And beautifully written. I hope that more physicians will consider hospice for their terminally ill patients.

Sara M. Barton said...

You did a nice job of showing the importance of having doctors who focus on "quality of life" care. It's kinder, gentler, and far more respectful of the needs of our loved ones. How sad that the hospice experience was so short for this patient. What opportunities did the families miss out on along the way?