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.