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Demystifying Medicine One Month at a Time

Tag: end of life care

End of Life Rallies

Let’s say your loved one is at the end of life. She’s 84, with advanced cancer that is no longer treatable.

A decision has been made to put her in hospice–which is a level of care more than an actual location. [Most hospice actually occurs at home.]

The patient waxes in and out of consciousness, sometimes lucid, but mostly not.

While no one is ready for her to die, this end-of-life process brings some solace–it’s what your loved one has indicated she wants, and the time at home without aggressive, often fruitless, medical treatment, allows other friends and family members to make visits and share stories.

One afternoon, she perks up and asks for a sandwich. This is surprising, because she’s barely eaten anything in the last ten days. But we get her that sandwich!

She nibbles at it, happy, but doesn’t eat much of it.

That afternoon, she’s talkative and engaged with others in a way that she hasn’t heretofore seemed able to muster.

Is she making a comeback? Healing from her illness?

More likely, this is what is called “rallying,” and while there’s ample anecdote of its occurrence in situations like this, we have very little understanding of it.

How does it happen? As a recent NYTimes article stated:

Physiologically, experts believe that the mind becomes more responsive when a hospice patient is taken off the extensive fluids and medications such as chemotherapy that have toxic effects. Stopping the overload restores the body to more of its natural balance, and the dying briefly become more like their old selves.

It’s deceiving because we think our loved one is getting better. And while she’s more like her old self, unfortunately, it’s not bound to last. Which is why it can be upsetting for some.

Spiritually, some suggest that the dying loved one is simply readying for transition–making sure that earthly concerns will be attended to in her absence and that final goodbyes may be uttered.

I’ve seen it–and especially in elders afflicted with dementia, it can be heartening to see them rally and seem to know what’s going on–accepting their impending death, and engaging with their loved ones before drifting off.

Orthopedic Dialogue

Six months ago I posted a story about a demented 94 year old patient who’d fractured her hip. She’d lost more than thirty pounds in the preceding months and had already had a collarbone fracture from a previous fall.

Pinning of a right hip fracture.

Pinning of a right hip fracture.

Her son wanted her to be made “comfort care only,” and avoid a trip to the operating room since she was likely within six months of death and was immobile (bedbound) even before her hip fracture. She was going to be referred to hospice. We called off the orthopedic consultants who had been kind enough to recommend (and set her up for) hip stabilization.

I felt like this was the right course of action–and the family members (the ones I’d met) supported this decision. The patient appeared comfortable, able to sit up in bed and hold conversations (albeit demented ones), and not in any distress from her fracture.

The next day, I came to the hospital to find out she was already on the operating room table to have her hip  “pinned.” No one had called me to discuss the change in plan.

I was furious. I felt betrayed by my orthopedic colleagues, who hadn’t seen fit to discuss their thinking or the change in planning (or the subsequent conversations with the family) with me. After all, I was the physician ‘in charge’ of the case; the one legally responsible for the decision-making and the outcome.

The blog post generated attention: commentary, multiple reposts (e.g. here) and some white heat.

I’ve learned a lot from the case, and from my posting of something so ‘fresh’ and full of emotion: Namely, that with the perspective of time, I now see that it was inappropriate of me to

  • blog about something so recent;
  • ‘call out’ my orthopedic colleagues without discussing the situation with them first;
  • use profanity in a blog post about something important and meaningful, thereby likely putting off the audience I would hope to capture.

I apologize for my boorishness. I was quite angry, and I let it get the best of me.

Many people wrote asking what the ‘resolution’ of the case was, and what the upshot of my post-hoc conversation with orthopedic colleagues would be.

I spoke with the department chair, after he’d had ample time to review the case and hear from the ‘players.’

I respect his approach and fact-finding, and he acknowledged that the communication over the patient’s fate (and consent to surgery) was mishandled. But he also helped me see the situation through the eyes of an orthopedic surgeon, which addressed my concern about their motivation(s). I will tackle his points one by one:

Hip fractures are an endemic problem. With our aging population and the thinning bone that comes along with it, hip fractures are an inevitability in communities and growing as a problem along with our aging loved ones. Primary care doctors do a lousy job treating osteoporosis.

Hip fractures are a local problem. At this one 500-bed hospital in a medium-sized American city, there were more than 800 hip fractures last year–more than 2 per day. The weekend before I spoke with the chairman, there had been seven hip fractures.

Orthopedic surgeons are not motivated by money when it comes to hip fractures. Unlike much of orthopedics which provides elective surgeries, hip fractures are a form of trauma, and therefore do not conform to surgical scheduling. Orthopedists perform fracture repairs as add-ons to their regular cases, and most surgeons don’t like to perform them as they occur at off-hours, over and above their regular caseloads. Medical outcomes in hip fracture improve the sooner they are repaired; therefore the addition of time pressure to these cases is another stressor for surgeons.

In the case I blogged about, the orthopedic group collected $819.27 in professional fees (i.e. the doctor’s charge) for the pinning of the 94 year-old patient’s hip. “Half of that goes to taxes, another quarter to overhead,” the chairman told me. That leaves a collection of about $205 net for the procedure. The implication is that no one is getting rich repairing hip fractures.

Communication is a two-way street. Much as I was displeased with the lack of communication in this case, the chairman provided several examples of where internists had simply not communicated with his team regarding a patient’s care. He’s absolutely right about this. It’s a fail for all of us.

They have created a center of excellence. One of the doctors who read my initial post works at the hospital in question. He pointed out, correctly, that NOT pinning the elder woman’s hip (even though she was emaciated, demented, and fragile) would be cruel. She would have pain with any position changes and likely develop bedsores. The standard of care is to repair hip fractures, not let them heal (they actually can!) over time. The time cost (and risk) is too great. That physician (an internist) has partnered with the orthopedic group to form a center of excellence in hip fractures, devoting resources to tackling this growing and costly problem in a systematic fashion. This is a great response–and I’m pleased to work and teach at a hospital that’s ready to tackle problems like this.

At the end of our chat, the chairman handed me copies of pages from the patient’s chart. “Is that your note?” he asked me. I nodded.

“I can’t read a word of it,” he told me.

Touche.

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