Sunday, December 30, 2012

'Twas the Day Before Christmas...

...and all through the hospital there were patients and families struggling with advanced illness despite the season. (Am I the only person who takes offense when hospital units are strung with wreaths and blinking lights, and orderlies wear Santa hats? Holiday cheer at the nurses' station seems a jarring, and potentially painful, contrast to what is happening inside patients' rooms.) We met with three patients and their families on Christmas Eve day, each with its own flavor, rhythm, and backstory.

Pedro was only in his early 40s, dying of advanced liver disease. When the liver goes, often the kidneys quit, too. We call that "hepatorenal syndrome," and dialysis -- what you'd normally think of when kidney fail -- is ineffective in this circumstance. The liver and kidney experts were tinkering around the edges, giving drugs and fluids in various combinations. But the blood tests were getting worse every day.

When I sat down with Pedro, I told him there was at best a 50-50 chance he'd live for another three months. He told me that he wasn't ready to die. His father had died two years ago -- ironically from kidney failure -- and Pedro and his two brothers were worried about their mom, who was clearly beside herself with grief. I explained why dialysis wouldn't help, why the medications weren't working, and that time was very, very short. We talked about his "code status" -- would he want us to attempt to bring him back if his heart stopped? -- and he was clear that the answer was yes. He did follow our advice and signed a form naming his brother Juan as his medical power of attorney.

Next door to Pablo was Bernie, a fellow in his late 60s who'd lost his independence as multiple episodes of pneumonia sapped his strength. Those, in turn, were probably caused by his difficulty with swallowing leading to aspiration. And all of that was set on the background of longstanding lung disease from a lifetime of smoking. Bernie had already made clear to me that he wanted nothing to do with resuscitation attempts. So our family meeting -- which included his sister and his ex-wife, with whom he'd maintained a cordial relationship -- focused on what was achievable and what the road ahead might look like. Bernie desperately wanted to return home, even if he would have to accept some help there. We talked about the possibility of that happening and how it would be hard to avoid at least a short-term nursing home stay with some rehab. His sister asked me to estimate how likely it would be for Bernie to get what he wanted, and I had to tell her he was facing long odds.

From there we moved on to the ICU to meet with Paula and her family. Paula couldn't participate in our discussions. A woman in her early 70s, she'd had metastatic breast cancer diagnosed a year before. Nothing worked, and she was in the ICU on a ventilator and sedation because she'd had overwhelming sepsis and two cardiac arrests in which the doctors and nurses were able to get her heart started again. "That's what's on her advance directive," one of them told me. The form she'd completed had two choices -- essentially, "let me go" and "keep me going even if I have to spend years on machines" -- and there was writing alongside the second choice.  I took a closer look. She'd placed her initials in the margin next to the "do everything" choice and written "NO" in capital letters in the space where her initials were supposed to be. She'd filled the form out backwards, or so it seemed. Her husband, sons, and daughter all confirmed that "this has gone on too long" and "she never wanted this." They were worried about her struggling for air if she came off the ventilator, so I walked them through our process for assuring that patients don't gasp or feel like they are choking. They seemed relieved but asked for more time to think things over.

So how did things turn out for my three Christmas Eve day patients? Christmas was on a Tuesday this year. By Friday Pedro had told everyone that he was at peace with dying. He agreed to permit a natural death and, trying to comfort his mother at the same time, moved to the inpatient hospice unit. Bernie was discharged from the hospital that same Friday to a nursing home, telling us he never wanted to come back to the hospital, that he knew that time was short, and that he realized he might never get home. And all of Paula's out-of-town relatives had arrived by Thursday evening. They said their good-byes, the ventilator was discontinued, and ten minutes later she was gone.

So three families struggled with hard choices on the day before Christmas, and ultimately each made the decision that was right for them. They faced reality. But the day before Christmas had a surreal touch, too, or so it seemed to me. A local funeral home placed this advertisement in the December 24th newspaper. I quote it exactly below with the original capitalizations and punctuations -- and no, I am not making this up:

Now through December 31, 2012, receive a free metal Casket with burial pre-arrangements or a Free Urn with cremation pre-arrangements. Happy Holidays!

I hope my readers' holidays were happy even without those free gifts, and may 2013 be filled with joy and peace for you and for all who suffer, no matter what the cause.

Tuesday, December 11, 2012


You know it's going to be a tough palliative care consultation if they wait until the day the patient is discharged before they call you, or if the patient is already crying when you walk in the door. With Serena, both were true. "She's being discharged to rehab today," the referring doctor told me, "but she seems reluctant to go. Can you talk with her about her goals and what she really wants?"

You might wonder why other doctors feel they need a specialist in palliative care to find out what their patients are hoping for, but such is the nature of modern medicine. Serena's first words, spoken through tears after I introduced myself, were, "Why are they sending me to rehab? I just want to die." That's the signal for many physicians to run for the exits. The experienced palliative care doc pulls a chair up close to the bed, leans forward, and asks something like, "What should I know about you to be sure you get the best care possible?" That's what I did. And so Serena told me her story:

A professional woman in her mid-sixties, she'd contracted a form of hepatitis over 20 years before. The virus had destroyed her liver. We have no good treatments for this problem, only delaying tactics, and Serena had run out of delays. Her liver disease was end-stage; she was jaundiced with a swollen belly and no energy; and she was likely to die in a few months. Her only hope was a liver transplant, but she had studied the procedure and decided that the risks weren't worth the benefits. "My liver doctor tells me to keep on getting treated," she said. "He tells me that I could see Paris. Well, I've already been to Paris four times. I'm miserable, and I don't see the point of going on."

Some patients hope they'll run into Dr. Kevorkian when they hear palliative care is coming to see them. It's my ethical responsibility to disappoint them that, no, I won't give them a shot to make them sleep forever and to tell them that, no, physician-assisted suicide is not legal in our state. I commiserated with Serena about the rehab plan. I agreed that it would probably not help and that she'd be in a nursing home soon. (She'd long passed the point where she could care for herself at home.) "But you do have an option that would get you what you seem to be hoping for," I told her. "You could simply decide to stop eating and drinking."

It turns out that death follows within a week or two after a patient elects to refuse anything to eat or drink. You'd think it's horrible, but it's not. People who've gone without eating for long periods -- hunger strikers, those on religiously motivated fasts -- say that their sense of hunger disappears after a couple of days. And the sense of thirst arises from the mouth, so keeping the mouth moist with an occasional ice chip or one of the commercial products developed for dry mouth means that the patient won't feel thirsty.

"You can make this choice anytime you like," I told her. "I can create a safe space for you in the hospital to die peacefully if you make that decision. All of our usual medications to treat pain and other symptoms will be available. And if you suddenly decide that this is a crazy idea and that what you really want is a burger and a milkshake, we'll call room service immediately." I gave Serena my card and told her that I would help her if she ever decided to call.

About a month later, she did just that. I made arrangements to bring her to my hospital, where she enrolled in hospice under the diagnosis of end-stage liver disease. I told the nurses the plan, and they told me they were in complete agreement. With that, Serena began her voluntary refusal of food and fluids.

Over the first two days, she had panicky episodes and wondered out loud if she was doing the right thing. I reminded her that the choice was completely hers, and that I could get her a glass of water in ten seconds and a tray of food in less than half an hour. She asked for and received medication for anxiety. On the third day, she requested water and a sandwich, which we provided immediately. She took a few sips and a couple of bites. Her two remaining family members arrived from out of town that same day. They all talked privately, and Serena told me that she really was done. Her relatives agreed. She declined any more food or fluids. Within 24 hours she was unarousable. Her face was relaxed, her forehead smooth, and she was breathing easily. She died two or three days later, never regaining consciousness and never showing any signs of distress. Her family thanked my staff and me for the excellent care we had provided.

When I tell this story to other doctors, some of them recoil in horror. But I think we did right by Serena. Whether you call it VSED (voluntarily stopping eating and drinking) or VRFF (voluntary refusal of food and fluids), this is a humane and painless way for a patient to take control and relieve intolerable suffering. All you have to do is say no.

Tuesday, October 16, 2012

Bleed Out

Charlene was tough -- feisty, independent, and absolutely clear about what she did and didn't want. And she communicated all of that without uttering a word.

Some time before our palliative care team met Charlene, she'd been diagnosed with squamous cell cancer of the throat. This is a particularly nasty form of cancer, usually associated with smoking and drinking, and difficult to treat. Charlene had gone through radiation treatments and was left with a permanent tracheostomy -- a trach ("trake") that allowed her to breathe but took away her speech. Nonetheless, with hand gestures, the use of a notepad, and -- most of all -- a set of withering facial expressions, Charlene could always get her point across.

She'd been admitted once again for mucus secretions that she couldn't clear on her own. She had a pattern of becoming frightened and showing up in the hospital's emergency department. Invariably she would be admitted for a few days. She would get some breathing treatments and would then demand to go home TODAY. Her handwritten notes always capitalized that word, or else she would write I WANT OUT NOW! We would try to talk with her about the pattern and about how accepting some help at home -- a visiting nurse, for instance -- might help keep her out of the hospital. Shaking her head violently, she always declined. She'd been like that her whole life, her family said. Her sister told us that she hadn't been inside Charlene's house for over 20 years. So we would shrug our shoulders, and Charlene and her husband would leave the hospital. You know that someone has become a "frequent flyer" when the staff takes bets about how long they'll remain out of the hospital. Charlene had been admitted at least weekly for many weeks. And to the frustration of the cancer wing staff, she insisted on remaining "full code." If her heart or breathing stopped, she wanted everything possible done to bring her back to life.

On her next to the last admission, I suggested a drug that might dry up her secretions. The hospitalist, who was in charge of her care, and I discussed the pros and cons. To my surprise, Charlene agreed to try it, and to my even bigger surprise, she said it was helping and not producing the dry mouth that patients on the medicine sometimes get. I talked with her again about accepting help. "If I try harder I can stay out," she wrote. I told her that she already was trying pretty hard. Borrowing a line from TV's Dr. Phil, I asked, "How's that working out for you?" She responded with a look that I'd come to understand meant "you are an idiot doctor who doesn't know a thing about me," or something like that. I made one more pitch for a home health nurse, which worked about as well as all previous pitches. So with a bit of mucus rattling in her trach, Charlene and her husband once again set out for home.

No one was surprised when she was readmitted four or five days later. But on her third hospital day, we were surprised to hear a Code Blue -- a cardiac arrest -- called for her room. The cancer eroded through a blood vessel near her trach, and there was nothing the code team could do to save her.

"A blessing," someone on the cancer wing said. "I don't think so," I replied. "She clearly had something in her life that, to her, was worth living for. I think that explains why she never changed her code status."

Charlene had a bad death by the standards that we in hospice and palliative care usually measure deaths by. But to the very end she appeared to have the life that she wanted -- indeed, the life she insisted on. "Do not go gentle into that good night...Rage, rage against the dying of the light," the poet Dylan Thomas wrote. Had she heard those lines, I have no doubt that Charlene would have given me one of her looks, and then nodded in agreement.

Sunday, March 4, 2012

A Tale of Two Cancers

Magdalena and Eric were across the hall from each other on the cancer wing. She was 72 and he was 27. What a difference a flipped digit makes.

Magdalena's widespread ovarian cancer had been diagnosed just two months before we met. She'd undergone heroic surgery, but it had not cured her cancer. And she had developed a non-healing abdominal wound that drained constantly Our wound care nurse is pretty experienced with this sort of thing, and she said this was one of the worst she'd ever seen. So Magdalena had spent over a month in the hospital, much of it in ICU, before being transferred to oncology. The surgeons and hospitalists involved in her care told the family they should consider hospice. They would hear nothing of it. "Well, how about palliative care?" they asked. It never works when my specialty is presented like that, as if it were hospice without the H. So naturally they rejected palliative care, too.

It was only when most of the family -- especially her oldest son Miguel, who ran the show -- recognized that she was in terrible pain that they asked if I would come and see her. She couldn't speak above a whisper, her forehead and brow were scrunched up, and she grimaced occasionally as she told me her pain was pretty bad. I looked at what she'd been receiving for pain. She had the right dose but the wrong schedule. I made a minor adjustment, and in an hour her pain was gone. Miguel and the other family members -- children, grandchildren, great-grandchildren -- all thanked me profusely. I took them aside and told them that she was not likely to survive the night.

There's an old saying that God is kind to fools and young doctors. There ought to be one that says God is particularly kind to doctors who are foolish enough to make predictions. The next morning Magdalena was sitting up, speaking in a normal tone, making jokes and thoroughly enjoying her family. "Be grateful for this gift," I told Miguel and some of the grandchildren. Magdalena's family enjoyed a few more days with her before she slipped into unconsciousness and died a peaceful death.

Across the hall, Eric was dealing with the knowledge that his stomach cancer -- very aggressive and very widespread when it had first been discovered three years earlier -- had come roaring back. And so had his pain. The nurses and I struggled for two weeks to get Eric's pain under control. Nothing worked -- not even three separate narcotics, each given in huge doses, along with several other so-called adjunctive medications designed to work in tandem with the pain-killers.

Eric had a young wife, a devoted family, and a deep religious faith that God would cure him. He, too, would hear nothing of hospice. So I offered him what we call palliative sedation. We'd administer medications that were intended to make him unconscious, since that seemed to be the only way to control his terrible pain. Most often, palliative sedation is not discontinued and the patient remains unconscious until death. For Eric I was offering a respite for a day or two; my intention was to stop the drug then and allow him to wake up. It's been reported that some patients awaken from respite sedation with their pain greatly relieved. So we tried it for two days. When the sedative was stopped, Eric had one good day before the cancer pain came roaring back again.

I kept adjusting the doses, tinkering here and there, hoping to get the desired result. Every time I went to see him -- and I was there several times a day -- Eric thanked me and shook my hand. He offered to pray for me, and I told him that many people were praying for him.

Three weeks into the hospitalization, Eric's pain suddenly worsened and then he could not be aroused. His abdomen became distended, his bowel sounds disappeared, and he winced when I pushed on his belly and then let go. He'd clearly had a catastrophic event -- maybe internal bleeding, maybe a hole in his intestine. We had come to the end of the line. Eric's wife wondered aloud about transferring him to a nearby academic center, but she came to understand that the outcome would not change. I strongly recommended restarting the sedative drug, and she and the rest of the family agreed. Eric's last day was spent in the company of many friends and family who prayed and wept at his bedside. I had struggled for three weeks to get him comfortable, and at least for the last twelve hours of his life he was.

Not all suffering is physical, and not all suffering can be relieved. It was easy for me to feel like a success with Magdalena. It was not so easy to avoid feeling like a failure with Eric. Not that Eric, or his wife, or any of his family ever uttered a word of criticism. They seemed to understand that I was doing the best I could. But it was hard for me to look in the mirror each morning and not feel the weight of Eric's unrelieved suffering.

Medicine, like politics, is the art of the possible. In palliative care you never know whether your next patient will be an Eric or a Magdalena. All that you do know is that you have to do what you can.

Thursday, February 16, 2012

Way to Go

Bertie was 91, and in an earlier, less politically correct era she would have been called spry. She'd been enjoying her life, which was happily free of major, chronic illness. She was surrounded by children, grand-children, and great-grandchildren, along with a network of friends and neighbors in her rural town. And she'd been married for over 60 years, although lately she'd been visiting her husband at a rehab center where he was recovering from a hip fracture. Bertie had barely been sick a day in her life.

About ten days before she died, Bertie had developed a stomach ache -- nothing serious, and nothing that had gotten in her way. Eight days before she died, though, the pain got much worse -- so much so that her family rushed her to the hospital at two o'clock in the morning. She was pale, weak, and in pain with a dangerously low blood pressure. Yes, the family said, we want everything done.

"Everything" meant a rapid-fire evaluation using the best that modern medicine has to offer. And that evaluation quickly revealed the problem. Bertie had a mass in her liver that was bleeding into her belly. It appeared to be a metastasis from the breast cancer that was visible on her CT scan and which also had spread to lymph glands in both armpits. Happily, the bleeding appeared to stop on its own, and after some fluids and transfusions Bertie appeared stable. Four hours after arriving in the ER, she was sent to intensive care.

At 9:30 that morning I walked into ICU planning to make rounds with the team. The attending asked me to see Bertie instead. Her life-prolonging options were bleak. Surgery was basically out of the question. The ICU team had thought about embolization -- threading a thin catheter into the bleeding area and shooting pellets into the vessels to cut off the blood supply -- but that would leave dead tissue behind to form a focus of infection that also would take her life. When the ICU folks can't think of anything else, they tend to think of me.

Bertie was being attended to by two of her children and several grand-kids. I sat down alongside her bed, introduced myself, and asked, "So what's your understanding of what's going on with you right now?" She looked me in the eye and said, "I'm going to die, and probably soon." "How are you doing with that?" I asked. "Oh, just fine," she replied, "I'm old, I've had a good life, and nobody lives forever."

I looked around and saw her children nodding in agreement, although they were tearful. "Well," I said, "let me explain where we might go from here." It's been my experience that patients and families often feel they have just two choices -- sticking with conventional, cure-oriented medicine (no matter how remote the possibility of cure), or doing nothing. "I'm here to tell you," I said to Bertie and her children, "that there's a third choice -- assuring your comfort for however much time you have left."

Bertie gave me a big smile and told me I was the best doctor she had ever met. Her smile wasn't forced; it was as if her whole body was smiling, and radiant, and at peace. Fourteen hours after arriving in the ER, Bertie was transferred to the inpatient hospice unit. She spent a couple of comfortable days there and then decided that she wanted to go home. The hospice team continued to support her and her family at home, where she died peacefully a week after our meeting in the ICU.

Now, I'm not at all sure if I was the best doctor Bertie had ever met. But I am sure that Bertie had a wonderful life and that she approached its end with the courage and grace that we all hope to achieve. She was clear-eyed and clear-headed every step of the way. Like everyone else she came into this world crying and screaming. But unlike so many, she showed us how to have a comfortable and gentle passing from this life to whatever may lie beyond.

Way to go, Bertie -- way to go.