You Never Know
So I've got another dying patient. We seem to go through cycles of this kind of thing (what V. calls "the thinning of the herd"). This fellow is in his nineties, has severe heart failure and kidney problems, and peripheral vascular disease (translation: his foot is turning blue due to lack of blood). He has lived at home with a caretaker and close attention from his daughter, but in recent months has become weaker, had multiple visits to the hospital, and has had two episodes of pneumonia in the last year. This time when he went to the nursing home for rehab he was too weak to participate in the therapy sessions, and he's stayed there ever since, more or less bedridden. The ulcer developed two weeks ago. The vascular studies I ordered confirmed that he needed surgery (you know it's not good when the report says "critical ischemia").
So I reviewed the report and thought: OK. This man would likely not survive surgery. He'd never consent to an amputation, and a vascular bypass on his leg would require an angiogram to see if he had operable disease; the dye used in the angiogram would likely wipe out his kidneys (which are hanging by a thread). After discussing all this with his daughter, she agreed with me and I referred him to hospice care. We're going to focus on pain control and comfort care.
When cases like this stick in your head, it's usually not the disease process that you're thinking of, it's the patient. So it is here. The case I just described is not unusual for internal medicine - a bundle of disease processes, each playing off against the other, forcing the doctor to choose a treatment strategy. Not that this isn't interesting - it has a lot to do with why I enjoy my job - but I'm remembering something else.
I picked this patient up about two years ago when his previous doctor left the group. His chart was the size of the phone book, and I was too busy keeping up with his meds and his various illnesses to go much into his past history. About two months ago, with the worsening of his illness, the patient became more depressed and I decided to get a psych consultation to see if medication would help. When I saw the consult note, this is what I read:
Patient is a Holocaust survivor. His first family (wife and children) died in the camps. After the war, patient remarried. His daughter Ms. X [who is the one who stays in touch with me]
is a product of his second marriage.
Holy crap. I didn't know.
I keep thinking of this man who fought so hard to survive, whose body is now betraying him and falling apart. He has his daughter, and his caregiver, so I suppose things could be worse; but I can't do much now except ensure him a comfortable death.
I will do that. I promised his daughter.
posted by Dr. Alice at #
