Yesterday, a patient told me that “nothing was being done” to treat the cancer that had been diagnosed four months ago. I pulled up the most recent oncology note in the computer and read the details to him. Of course the oncologist had told him everything I was telling him. Why did the patient not know that he had a follow-up appointment scheduled? The clue was at the end of the note. “Patient is requesting Valium. Will defer to his primary care provider.” A complicated diagnosis and treatment plan was carefully laid out to a patient who was too anxious to hear any of it.

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This was the first time I met this patient in Palliative Care clinic, and the most obvious thing about him, the point that dominated the resident’s presentation, was the patient’s anxiety. Apparently the resident was so impressed by the anxiety, that he neglected to tell me some pertinent medical history before I entered the room. Thinking back on it, I wonder whether the resident had the misguided notion that Palliative Care is only about psychosocial issues, not about practicing good clinical medicine. I hope he learned from my example as I looked up the summary of the hospitalization from last August and all of the oncology notes.

When residents come to Palliative Care clinic for the first time, I tell them it’s no different from practicing Internal Medicine, but with a slightly different focus. I use the acronym GAPS to help them remember what to focus on in addition to the standard medical assessment. (more…)

The whole Palliative Care community was saddened to hear of the death of Dr. Andy Billings. You can find his obituary here, and you can learn more about him in this article from the New York Times on “How Doctors Die.” I learned of his death just hours before I was scheduled to present a journal club to the Internal Medicine residents I teach. As synchronicity would have it, the articles* I was presenting were the three that Dr. Billings had written on how to run family meetings in the ICU. I felt that Dr. Billings’ spirit was guiding me as I asked the residents to role play and then debrief a difficult ICU family meeting scenario.

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I would never have had the courage to try something like this had I not watched Dr. Billings lead a group of physicians through the same process back in 2010. I came away from that seminar with a clear vision of what a family meeting entails, how it’s a division of expertise. The health care team and the family meet and share what they know. The physician is the expert on the clinical circumstances, but the family is the expert on the patient, on who he was and on what he would say if he could speak for himself. It was a simple but elegant way to describe the concept of substituted judgment. Ideally, if there’s no written advance directive, the family doesn’t have to make decisions for the patient. They merely have to express the known wishes of the patient. It may seem like a subtle difference, but it takes a lot of the stress and guilt away when making life-or-death decisions. (more…)

The physician leader literature is full of references to “the disruptive physician,” the one who openly humiliates and bullies other providers on the health care team. Often, one thinks of an older male physician denigrating a younger female nurse. Lack of open communication in health care, though, with team members failing to speak up on behalf of a patient, may deal with a subtler, more pervasive type of intimidation.

Photo Credit: Robert Churchill

Here’s something that happened in my hospital. An ICU “family meeting” was called to try to determine whether a patient should proceed with with having a percutaneous endogastric (PEG) tube placed. The patient had lived an astounding 69 years with Down Syndrome, but had not been spared from its complications, most notably early onset dementia. She was fully dependent on others and bed-bound by the time she came to our hospital.

The geriatric literature is clear: patients with end stage dementia should not have a PEG tube placed because the burdens outweigh the meager benefits. (more…)