On a long week (or halfway through Internal Medicine)

This week, I’ve held one family meeting, one end of life discussion, and received some heartening feedback from a preceptor.

On Monday, I sat down with a patient and her husband. The previous week, I attempted to arrange a consult with OACIS, our palliative care team, to discuss her goals of treatment. She is in her late fifties, has severe COPD, and spent more time in the hospital than at home over the past three months due to acute exacerbations. Most recently, she had been discharged less than 24hrs before readmission due to shortness of breath.

Much of the staff roll their eyes when we discuss her case, from the med techs to the nurses to the residents and even some of the attendings. They see where she is, not where she could be. She’s got her first granddaughter coming, to be delivered via c-section late next week. Her mother’s health is failing and she feels obligated to care for her. And yes, she does request and sometimes demand pain medication, but the staff doesn’t seem to correlate her activity levels with her pain management: when she’s hurting she stays in her chair and when we increase her pain regimen, she walks the halls and battles steps with PT.

And because of a scheduling issue, OACIS was unable to see her. So, I’m it. No one else wanted to sit down with her and ensure she understood the causes of her morbidity: long-term systemic steroids have weakened her bones which created the susceptibility to fractures from her coughing fits and also suppressed her immune system causing recurrent bouts of pneumonia.

With her and her husband, we talked for about an hour and a half. I opened with a discussion of responsibility: what does it mean to be responsible for someone or something? Picking up after someone’s mess? Paying the bills? Me personally, I think the greatest declaration of responsibility is to do all of that for the final time.

When someone dies, it’s great if you’ve cleaned their room and washed their body for the past five years, but who will do it when the life has left the meat? And I’m not saying that I want to be this responsible for this patient. I just want to make sure that someone will.

From there, we discussed the three paths for her health: that she gets better, that her health stays the same, and that her health declines. It’s possible that the first two happen. It’s definite that the final one occurs, the only question is when.

And so we talked about her granddaughter and her mother. We talked about service and how she deeply wants to help her family survive and to counsel her son as he navigates adulthood.

Then, we talked about the barriers to that outcome of better health. How we need to wean her off the steroids but also maintain levels for proper management of her lungs and breathing. How her pain is in the front of her mind but truly a secondary problem to her beat-up airways.

Finally, we talked about end of life.

How does she want to die?
In her sleep at home.

What kind of service does she want?
Nothing fancy and definitely not at a church because she didn’t attend during her life and doesn’t want her children to experience that dissonance.

How does she want her body to rest?
Cremation, because she has a deep and powerful fear of worms so burial is out of the question.

And throughout the long and winding conversation, I got a sense of the powerful relationship between them. He had her back and she held the family together. There were times when she talked about her death that he stared off into the distance of the window. She wiped tears away when he wasn’t looking.

We ended the discussion with hugs all around and a plate of hot food arriving straight from the cafeteria. I left the room and gave myself a few minutes alone before resuming my duties as a medical student.

The next day, I returned to her room early in the morning with her husband already there. He brought mail and she gave him a hard time about not bringing everything she requested. A lovely display of tough love tempered over the years. She wanted information from her life insurance, just in case.

At the end of the week, my attending physician gave me feedback on my performance as a student and future physician. For a while there, he thought her husband’s name was Eugene because of how often she talked about me. He had worked with her before and mentioned that this was the most positive and optimistic he has ever seen her. He told me that he could definitely see me in psychiatry, because I seem to be drawn towards the difficult cases that others would run away from.

I won’t tell you about the end of life discussion, at least not this week. His story is still being told. I’ve learned so much over the past six weeks. Some of it is directly related to internal medicine: the brand names of drugs, how to write effective notes, and the acceptable amount of stretching during the morning rounds.

The majority of my lessons these past six weeks seem to prepare me for a career in psychiatry: how to quickly build trust with a patient, how to broach difficult conversations, and how to maintain a therapeutic relationship. Perhaps that is simply the basis for a good physician, not just a psychiatrist.

I look forward to the next week, in the Emergency Department. The pace will change dramatically from one or two cases a day to half a dozen throughout a shift. The depth of interaction will change from several conversations over a week to a handful of minutes for a history and physical.

My newly earned skills will be put to the test: can I still connect with patients in the chaos of the ER? The length of the interaction will change dramatically, but can I keep the depth?

And if I can, should I?

Long Form Sundays

On Death Podcast

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