The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Wednesday, November 22, 2006

Dr Death

Over lunch this week, my preceptor and I headed out into the community to make a few house calls. Yup, you heard right. On occasion we hit the road to visit patients who can't make it in to the office. Or, at least, can't easily make it into the office. This usually consists of palliative care patients and the occasional melodramatic Italian granny who enjoys making a show of staying in bed making enthusiastic proclamations to God and having her extended family wait on her hand and foot.

On this day in particular, the road show consisted of one of each of these typical patients. As we left the home of the Italian grandmother (with a bottle of homemade wine in hand as a token of the family's appreciation) I scanned the file of the palliative patient. A 72-year-old man with a diagnosis of metastatic gastric carcinoma. Since the time of his initial diagnosis he had been through the roller coaster of surgery, chemo and radiation, each treatment bringing the family hope until the test results came back... it was still spreading.

His appearance was startling. His face, gaunt and angular, smiled at us as we came through the door. Snaking out from under the covers were numerous lines, many of which his life was dependent on-- one drain from his peritoneum draining his ascites, one from his chest draining the recurrent pleural effusions, the catheter draining his bladder and the IV replacing all the fluids being drained out. An uneasy balancing act. In spite of the hard round belly protruding from his t-shirt, the skin hung off his bones in the characteristic manner of rapid weight loss and muscle catabolism. With the exception of his grin, he looked as though he had died days ago.

His wife beamed by his side.

"He's feeling much better," she told us, "all we need to do is get him back on his feet!"

My preceptor and I exchanged uneasy looks. He had already briefed me on the fact that the family didn't seem to really accept his dismal prognosis. He gently explained to the couple that he really wasn't expected to get any better, and that we should likely discuss what the plan was if he were to get worse.

"Well, we'd bring him to the hospital!" the wife said, confused. "And take him back here as soon as he improves."

The patient was still full code. Most cancer patients are made DNR long before they reach this point. This man's family wasn't willing to give up their hope for a miracle.

"Oh," the wife exclaimed, "I almost forgot. Our home care nurse was telling us that we should get a referral for Dr. X. She's supposed to be an expert in pain control, and she'll come right to the house."

My preceptor blanched. "I don't think we're quite there yet."

The wife was confused. "What do you mean?"

He backtracked. "I just don't feel that there's anything she can offer your husband that I can't do for you just as well. His pain is well controlled right now. I just don't think he's... sick enough... for that at this point."

My preceptor is a good family doctor. His patients trust him. In this case, his word was enough to appease this family.

In the car on the way back to the office, I questioned him about this. Who was this doctor? A palliative care physician? Why not consult her? Maybe it would save us from driving 20 minutes out of town to check on this man on a weekly basis.

"The family isn't ready for that step."

"What do you mean?" I pressed further, "what could it hurt?"

My preceptor sighed. "Every patient I've referred to Dr. X. has been dead within 48 hours of seeing her."

I digested this information. Then it dawned on me what he was trying to say.

"You mean... she helps them die?"

"I'm not saying that. I have no way of knowing..."

"But that's what you think."

He nodded. "When the family is ready to let go, I'll involve Dr. X. But right now, as long as he's pain-free and the family believes he'll recover, it's not time."

We sat in silence for the remainder of the trip. As much as I believe that people should have the right to end their own lives when they see fit, to be faced with it in reality was awfully sobering.

I still have so much to learn.

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7 Comments:

Blogger A H said...

Such a clear and concise narration. Medical School obviously hasnt managed to beat your well roundedness. Kudos to your spirit!

9:53 PM

 
Anonymous Anonymous said...

EXTRAORDINARIO.


JORGE

9:58 PM

 
Blogger Simon said...

Hallo,

I was just reading some of your old posts about CaRMS. It truly is severe suffering.

I think it may actually be one of the few things in my life that actually lived up to the hype of being as sucky as everyone said it would be. It is truly very sucky.

Nice blog!

2:33 AM

 
Blogger Laetitia's mummy said...

It breaks my heart that the family still holds on to so much hope though there seems to be none. Must be difficult to be faced with such situations as a doctor.

11:11 AM

 
Blogger Ex Utero said...

My father died of stomach cancer. In most cases it takes the liver, but up until the point they go into a hepatic coma, it is a truly awful death.

His death was actually the catalyst that got me writing again and a big part of my first book. Despite that, Dr X sounds pretty murky to me. I'm with John Crippen on this one. People can take their own life if they're smart enough and motivated to avoid a bad ending, but doctors have sworn an oath and patients need to know that we can and do draw a line. Note that this does not stop us from giving adequate pain control, even when adequate pain control results in gradual respiratory compromise. I am very comfortable with that titration.

10:40 PM

 
Blogger Kungfukitten said...

Well maybe that family attitude will bring that man a few more months without pain that he would no longer have. I just hope that someone there knows the real score on his condition. I'm all for - uh, Dr. X's compassioin - then again I live in Oregon.

12:15 AM

 
Blogger Gabrielle said...

This may sound ignorant (I hope not) but I have always wondered why there isn't training provided for those who wish to be Dr. Death? There should be doctors who are death dealers and assist those who will not get better as well as their families. It only makes sense. The Western world seems so afraid of death--we attempt to make people live even when we know they'll die...WTF SERIOUSLY! I have watched the suffering of someone with cancer...her family hung on so long the woman was putrid and decaying before she formally died! She wanted to go but the doctor kept doing what the family wanted...KEEP HER ALIVE. I don't get it...but that's just me. If there were an option to be Dr. Death I'd choose it over general surgery...wishful thinking I supposed.

12:42 PM

 

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