Tuesday, April 2, 2013

Healthcare's Dumping Ground?

I couldn't really blame the social worker.  He was just doing his job.  The SNF unit connected to the hospital was full of flailing patients.  So he thought he would ask for a palliative care consult (after getting an okay from the primary team).  It was his third request of the day.  He spoke slowly as he tried to untangle the twisted path the patient had taken.

Dr. X was managing poor old failure to thrive before he came to the hospital.  But then Dr. Y, the hospitalist, admitted him and treated the urinary tract infection.  Dr. Z was covering Dr. W on the cardiology side.  And of course Dr. S, the oncologist, was giving chemo before he landed here.

My head started to swirl as I waived him away and ambled back to the nursing station.  This was another complex patient with multiple doctors and few answers.  I reviewed the chart and then went to the room and began my exam.  He was an elderly, confused, chronically ill gentleman with labored breathing.  He was unable to communicate effectively. 

I left the room and called the daughter.  She hadn't spoken to any of the doctors in awhile.  She was hoping to meet later in the day to talk.  I hung up and paged the nurse practitioner who covered the hospitalist patients in the SNF.  Even a move down the hallway ended in a hand off to yet another provider. 

It was just as I expected.  Doctor X didn't come to the hospital.  Dr Y had finished his week as hospitalist and was now off for the next seven days.  Dr. Z and Dr. W signed off the case since the cardiomyopathy wasn't responding to maximal therapy.  And Dr. S, the oncologist said that the metastatic prostate cancer was the least of the patients problem. 

So it would be me, the newly consulted palliative care specialist, who would sit down and talk to the patient's family about end of life and futility.  I would start a little morphine, tweak a few medicines, and stop the ativan due to delirium.

I have to admit that it all left a sour taste in my mouth.  This is just one example of many.  Yes, this is what we are good at, but it also kind of makes me wonder.

Has palliative care become the last bastion of sanity in the dumping ground of today's disjointed and broken healthcare system?


sjdmd said...

Your right so far as you go, but for another point of view of the start of the cascade read http://sjd.md/XoRegW

Unknown said...

Sad and frequent story. I think that the sour taste may come not from being the last bastion of medicine, maybe more from being anticipated. Why not first a classical internal medicine approach?

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