These past four weeks have been some of the most painful I've ever experienced in residency. My attending admits patients from her office like there's no tomorrow (one day we got eight new patients in 24 hrs), completely disregarding our team cap (14), then becoming frustrated when we don't know what's going on with the patients that overflowed to other teams. The general medicine teams don't appreciate our overflows either (just like I dislike having general medicine overflows to my team), and the worst part is, it is extremely hard to discharge patients on this service. My attending is very good with her patients and they love her, but she gives in to them too much. We have a patient on our service with C. Diff who could have gone home days ago, but can't because her insurance won't pay for her antibiotics so she's just getting them here. Another guy could have gone home today, but we're babysitting him just in case his WBC drops (after chemo). Seriously? His WBC went from 4 to 16 after getting neupogen! Today we had 8 possible discharges; by the end of the day, NONE of them went home. A big reason for this was that we rounded with a more junior attending who was afraid to do ANYTHING without my attending's consent; his response to the patients was, "We'll see what Dr ____ says tomorrow." Does he not understand I am trying to get these patients OUT?!
I imagine my fellow, my intern, and med students probably think I'm becoming more and more callous because I keep trying to get my patients out of the hospital. And with good reason: for the past 48 hours I have been caring for 15 patients, which is one above our cap. And some of these guys are sick. One of my sickest patients is a ticking time bomb; his pancreatic tumor has invaded into his stomach, causing a massive GI bleed several days ago. GI and IR have said there is nothing they can do and recommended palliative care. The bigger shock was when the surgeon told the patient how extensive his cancer was and his caretaker tried to stop him from saying too much. As it turned out, the patient had absolutely no idea that his cancer was so extensive. He knew he had a "tumor" in his abdomen and that he was getting treatment for it with chemoradiation, but no one in his family told him that the tumor had taken over his liver or that he could possibly bleed to death at any time. I don't know if it was done to protect him or what, but at any rate, he knows now that his cancer is much more serious than he thought. It's a shame that the cat was let out of the bag the way it was, but I think it's better this way.
With an average census of 14+ patients for the past two weeks, I feel like I'm being torn apart. I'm trying to do my job and be the best resident I can be for these patients, but between social placement issues and my attending endlessly admitting/never discharging her patients, things are getting out of control. I tried to dictate a patient's discharge summary today, and when I played back my dictation, my voice sounded completely defeated and tired, almost like I was on drugs. This service is sucking my soul away, and I'm beginning to lose myself. Even an impromptu trip to New York the other day to watch the Spiderman musical (which I thought was exciting and well done) did nothing to boost my spirit. My only consolation is that I have only 3 days left on this godforsaken service, and after that, three friends and I are going to watch the Philly orch perform Debussy's "La Mer." Let's hope I'll make it 'til then.
Wednesday, March 28, 2012
Monday, March 19, 2012
Choosing Death Over Life
One of my more unusual admissions was a 57-year-old man named Dan who was sent to the hospital from his oncologist's office for, of all things, "suicidal ideation." Three years ago he was a healthy gym teacher who did everything right in life. Then he was diagnosed with nasopharyngeal cancer, and radiation treatments worsened his ability to swallow, causing him to require a feeding tube and depriving him of the joy of eating what he liked (at best, he could eat soft foods). Then, he was recently diagnosed with a second cancer (lung), and even worse, it had spread to his bones. He became both depressed and discouraged to the point where he threatened to stop eating at home, saying that he wanted to die. It took my attending an hour to convince him to come to the hospital for treatment of dehydration.
When I first met him, he looked absolutely miserable, barely making eye contact with me or the nursing aide watching him (to make sure he didn't try to kill himself), and when I asked if he knew why he was in the hospital, he said, "Yeah, I want to die." He was tired of living with the knowledge that his cancer was no longer curable, and would eventually disable and kill him (the RNs said he used to do pushups in the hospital room when he was first diagnosed). We consulted psych and started him on Zyprexa to see if it would help his mood (it didn't). He also complained of intractable hiccups, so we gave him thorazine. He was also neutropenic and spiked fevers almost daily (though we had no obvious source of infection, as his CXR looked clear). The nurses who knew him gave him pep talks to keep his spirits up, and even my attending told him that since the cancer had only spread to his bones, he could continue to receive radiation and live a relatively normal life (since the cancer had yet to spread to his liver or other organs). I thought he was starting to believe him, but then he developed a bad case of rigors (presumably neutropenic fever) that knocked him down. That was the beginning of the end.
The following day was my day off, but I still came to work in the afternoon to prewrite my notes. My intern was nowhere to be found, and I later learned that he was with Dan, who had a rapid response called on him for rigors and hypoxia. His CXR, to our horror, showed new pulmonary edema that was NOT present just two days ago; his lungs had a lot of "fluff" that looked like ARDS. A MICU eval was called, and the MICU team wanted to intubate him. Dan refused. He made it very clear to the MICU team that he did not want to be intubated, even if it would save his life, and he didn't even want to wear a BiPAP. He just wanted to be comfortable. Normally the advance directive forms in our hospital don't allow patients a place to sign (the attending usually signs it); Dan, however, was so insistent that he wanted no life-saving measures that he signed his name on the side of the paper, at least until the attending signed it the following the day, to make it as official as possible. His older brother, who was also visiting, disagreed with Dan's choice and started arguing with him in the room while he was struggling to breathe; security had to get involved and they ended up banning the brother from entering the hospital "under any circumstance." I felt bad for the brother, as none of us were truly comfortable with Dan's decision to withhold care and felt that if he gave intubation a chance, he could potentially make it through this. But in end-of-life care, the patient has the final say.
DNR doesn't mean Do Not Treat, so we started him on a heparin drip (in case of PE) and gave him a huge dose of Lasix in hopes it would clear the fluid that was building up in his lungs. Dan spent the remainder of the night with his wife at his side, and they made small talk about friends and family. He desat again in the early hours of the morning and finally had no choice but to wear the BiPAP to help him breathe. Sometime around 7:30 a.m., he told his wife that he was thirsty, and she left the room briefly to go to the cafeteria.
I entered the room around 7:50 a.m., and I immediately noticed that the BiPAP was off and in Dan's hand, which was resting at his side. Slumped to one side, his breathing was agonal now, one breath every 20-30 seconds, and he didn't respond when I called his name or shook his shoulder. I immediately knew that the end was approaching, and with the help of a nurse we repositioned him to help him be more comfortable. I saw several more patients before returning to the room and saw his wife waiting outside while techs took a chest Xray (which had been ordered previously but I knew was now futile). I told her that he was now unresponsive, which was a huge shock to her. "I was just talking to him! We talked all night!" she said. As soon as the X-ray tech left the room, both of us went inside and found the patient lying still in bed. He was so thin that previously I could see his carotid pulsating in his neck; now everything was still. With a sinking feeling, I realized that he had died during the X-ray, or even before.
"Dan? Dan, wake up!" his wife said as she shook his shoulder. I quickly ran into the hall and asked the nurses for a flashlight to confirm that Dan had died. No breath sounds, no heart sounds, pupils fixed and dilated. Time of death 8:30 a.m. His wife burst into tears, unable to believe that he was gone after he was just talking to her two short hours ago. I felt extremely sad, too, but in a strange way, I felt that Dan would not have wanted it any other way. I had heard that he didn't want to prolong his illness because he didn't want his wife (whose first husband had also died of cancer) to go through the pain of watching another husband slowly die. I think that he waited until after she left his room to let go, so that she wouldn't have to watch him take his last breath. Afterwards, we left him in his room for several hours while his family and former students came to say goodbye, and his wife thanked us for being so understanding.
Dan came to the hospital saying that he wanted to die, that he was tired of getting treatments to delay the inevitable, and he finally got his wish. He never had a choice when he was diagnosed with not one, but two cancers, or when he needed a feeding tube to sustain him when he could no longer swallow properly, but in his final hours, he was able to choose how he wanted to die. Not in the ICU, not intubated and hooked to monitors, but in a quiet room after spending the night with his wife at his side. It's some consolation to know that Dan died on his own terms, in the way he wanted. That was one thing not even cancer could take away from him.
When I first met him, he looked absolutely miserable, barely making eye contact with me or the nursing aide watching him (to make sure he didn't try to kill himself), and when I asked if he knew why he was in the hospital, he said, "Yeah, I want to die." He was tired of living with the knowledge that his cancer was no longer curable, and would eventually disable and kill him (the RNs said he used to do pushups in the hospital room when he was first diagnosed). We consulted psych and started him on Zyprexa to see if it would help his mood (it didn't). He also complained of intractable hiccups, so we gave him thorazine. He was also neutropenic and spiked fevers almost daily (though we had no obvious source of infection, as his CXR looked clear). The nurses who knew him gave him pep talks to keep his spirits up, and even my attending told him that since the cancer had only spread to his bones, he could continue to receive radiation and live a relatively normal life (since the cancer had yet to spread to his liver or other organs). I thought he was starting to believe him, but then he developed a bad case of rigors (presumably neutropenic fever) that knocked him down. That was the beginning of the end.
The following day was my day off, but I still came to work in the afternoon to prewrite my notes. My intern was nowhere to be found, and I later learned that he was with Dan, who had a rapid response called on him for rigors and hypoxia. His CXR, to our horror, showed new pulmonary edema that was NOT present just two days ago; his lungs had a lot of "fluff" that looked like ARDS. A MICU eval was called, and the MICU team wanted to intubate him. Dan refused. He made it very clear to the MICU team that he did not want to be intubated, even if it would save his life, and he didn't even want to wear a BiPAP. He just wanted to be comfortable. Normally the advance directive forms in our hospital don't allow patients a place to sign (the attending usually signs it); Dan, however, was so insistent that he wanted no life-saving measures that he signed his name on the side of the paper, at least until the attending signed it the following the day, to make it as official as possible. His older brother, who was also visiting, disagreed with Dan's choice and started arguing with him in the room while he was struggling to breathe; security had to get involved and they ended up banning the brother from entering the hospital "under any circumstance." I felt bad for the brother, as none of us were truly comfortable with Dan's decision to withhold care and felt that if he gave intubation a chance, he could potentially make it through this. But in end-of-life care, the patient has the final say.
DNR doesn't mean Do Not Treat, so we started him on a heparin drip (in case of PE) and gave him a huge dose of Lasix in hopes it would clear the fluid that was building up in his lungs. Dan spent the remainder of the night with his wife at his side, and they made small talk about friends and family. He desat again in the early hours of the morning and finally had no choice but to wear the BiPAP to help him breathe. Sometime around 7:30 a.m., he told his wife that he was thirsty, and she left the room briefly to go to the cafeteria.
I entered the room around 7:50 a.m., and I immediately noticed that the BiPAP was off and in Dan's hand, which was resting at his side. Slumped to one side, his breathing was agonal now, one breath every 20-30 seconds, and he didn't respond when I called his name or shook his shoulder. I immediately knew that the end was approaching, and with the help of a nurse we repositioned him to help him be more comfortable. I saw several more patients before returning to the room and saw his wife waiting outside while techs took a chest Xray (which had been ordered previously but I knew was now futile). I told her that he was now unresponsive, which was a huge shock to her. "I was just talking to him! We talked all night!" she said. As soon as the X-ray tech left the room, both of us went inside and found the patient lying still in bed. He was so thin that previously I could see his carotid pulsating in his neck; now everything was still. With a sinking feeling, I realized that he had died during the X-ray, or even before.
"Dan? Dan, wake up!" his wife said as she shook his shoulder. I quickly ran into the hall and asked the nurses for a flashlight to confirm that Dan had died. No breath sounds, no heart sounds, pupils fixed and dilated. Time of death 8:30 a.m. His wife burst into tears, unable to believe that he was gone after he was just talking to her two short hours ago. I felt extremely sad, too, but in a strange way, I felt that Dan would not have wanted it any other way. I had heard that he didn't want to prolong his illness because he didn't want his wife (whose first husband had also died of cancer) to go through the pain of watching another husband slowly die. I think that he waited until after she left his room to let go, so that she wouldn't have to watch him take his last breath. Afterwards, we left him in his room for several hours while his family and former students came to say goodbye, and his wife thanked us for being so understanding.
Dan came to the hospital saying that he wanted to die, that he was tired of getting treatments to delay the inevitable, and he finally got his wish. He never had a choice when he was diagnosed with not one, but two cancers, or when he needed a feeding tube to sustain him when he could no longer swallow properly, but in his final hours, he was able to choose how he wanted to die. Not in the ICU, not intubated and hooked to monitors, but in a quiet room after spending the night with his wife at his side. It's some consolation to know that Dan died on his own terms, in the way he wanted. That was one thing not even cancer could take away from him.
Sunday, March 11, 2012
When the Young (and Old) Have Cancer
This month I'm doing an oncology inpatient service (originally requested when I dared to dream that I would one day become an oncologist), and after working for seven days straight, I already feel burnt out. There was one day where my census was 7; after that it exploded to 14 and has stayed above 10. And these patients are sick. My attending is a very nice woman, but she also has the mindset to treat patients until the very end, giving people chemo at the cost of quality of life, and refusing to make her patients DNR/DNI as she believes residents take less care of them once they're labeled with a DNR (not true). She has a tendency to make promises to her patients that everything will be all right, and it frustrates my fellow and me to no end when the promise is being made to a stage IV cancer patient who has weeks or months at best.
Sadly, my service this week was full of young people with deadly disease. One was a 34 year old guy with metastatic CA who initially was seeking treatment at Cancer Treatment Centers of America, but came to us when even CTCA deemed there was nothing more they could do. (We half-joke that when patients from CTCA are transferred to our hospital, they come to die, because it happens like that all the time). He developed a bacteremia sensitive to everything but colistin (a last line antibiotic that eventually causes kidney damage to all who receive it), and while we continue to give him chemo, his kidneys are taking a huge hit. So what's the better option, go on dialysis or die of sepsis? His family and young children came to see him over the weekend, and it was sad to hear them ask nurses if he was going to get better. And we all know the answer is no. When I see him, I think of Bryan and Heather, and wonder how they are doing now that Bryan is home on hospice.
Two other patients have rhabdomyosarcoma (rare and deadly), and both are younger than me. One was 18 weeks pregnant when she was diagnosed and had to have a therapeutic abortion to give her a chance to receive chemoradiation and live, not just for herself, but her other children. The other noticed something was wrong but was unable to see a doctor because he had no insurance; now the sarcoma has spread to his lungs. But both are optimistic and hopeful, and hopefully their youth will act in their favor. But it still saddens me to see them in this position; when I was 26, my biggest worry was where I would go for residency, not how long I'd live.
One of the more interesting things about taking care of cancer patients is seeing how family dynamics work in light of a fatal diagnosis. Today was my post-call day, so I could have left at 1 pm at the earliest; instead, I stayed until 5 pm as though it was a regular day, because two of my patients were actively dying. Both of them are longtime patients of my attending, and a part of me is afraid that when she comes back tomorrow, she'll accuse me of being a black cloud since they got so sick. One was a woman with stage IV colon CA with huge liver mets who's biggest problem was her recurrent ascites. When I first met her, she was completely awake and oriented with a sweet personality. This morning I found her staring at the wall, barely responsive to voice and not following commands. Her ammonia had risen from 186 to 460 overnight. The attending on call immediately called the daughter and said that her mother was dying and needs to be on hospice, and palliative care was immediately contacted. The family accepted the situation and all gathered around her room to talk to her and keep her comfortable.
This was a complete contrast to the other family, whose 86-year-old father was dying of metastatic pancreatic cancer. He was on our service last week for hematuria, and at that time he was able to have a lucid conversation, follow commands, and eat small amounts of food. His family brought him back after he stopped eating, and now his speech is garbled and he keeps moaning. His wife and daughter were notorious throughout the cancer floor for stalking nurses and being demanding, keeping him full code despite his poor prognosis. Their biggest concern was that he was not eating, and wondering why he no longer recognized them and why his mental status has gone down the toilet. My attending explained that the patient was actively dying, and that not eating and hallucinations were part of the dying process. We then tried to bring up the idea of DNR, which the wife (and primary decision maker) seems to agree with. Her children were another story; a son I had never met until today pretty much said that doing nothing went against what the Torah stated (they're a Jewish family). The wife seems to be the most reasonable of the bunch right now, so I hope the whole family will come around soon. I'd hate to be the resident to code this poor man.
It's days like these where I'm glad that I'm not specializing in oncology after all.
Edit: The pancreatic cancer patient died two days after this post; by then, the family had made him DNR/DNI and comfort care, and he died surrounded by family.
Sadly, my service this week was full of young people with deadly disease. One was a 34 year old guy with metastatic CA who initially was seeking treatment at Cancer Treatment Centers of America, but came to us when even CTCA deemed there was nothing more they could do. (We half-joke that when patients from CTCA are transferred to our hospital, they come to die, because it happens like that all the time). He developed a bacteremia sensitive to everything but colistin (a last line antibiotic that eventually causes kidney damage to all who receive it), and while we continue to give him chemo, his kidneys are taking a huge hit. So what's the better option, go on dialysis or die of sepsis? His family and young children came to see him over the weekend, and it was sad to hear them ask nurses if he was going to get better. And we all know the answer is no. When I see him, I think of Bryan and Heather, and wonder how they are doing now that Bryan is home on hospice.
Two other patients have rhabdomyosarcoma (rare and deadly), and both are younger than me. One was 18 weeks pregnant when she was diagnosed and had to have a therapeutic abortion to give her a chance to receive chemoradiation and live, not just for herself, but her other children. The other noticed something was wrong but was unable to see a doctor because he had no insurance; now the sarcoma has spread to his lungs. But both are optimistic and hopeful, and hopefully their youth will act in their favor. But it still saddens me to see them in this position; when I was 26, my biggest worry was where I would go for residency, not how long I'd live.
One of the more interesting things about taking care of cancer patients is seeing how family dynamics work in light of a fatal diagnosis. Today was my post-call day, so I could have left at 1 pm at the earliest; instead, I stayed until 5 pm as though it was a regular day, because two of my patients were actively dying. Both of them are longtime patients of my attending, and a part of me is afraid that when she comes back tomorrow, she'll accuse me of being a black cloud since they got so sick. One was a woman with stage IV colon CA with huge liver mets who's biggest problem was her recurrent ascites. When I first met her, she was completely awake and oriented with a sweet personality. This morning I found her staring at the wall, barely responsive to voice and not following commands. Her ammonia had risen from 186 to 460 overnight. The attending on call immediately called the daughter and said that her mother was dying and needs to be on hospice, and palliative care was immediately contacted. The family accepted the situation and all gathered around her room to talk to her and keep her comfortable.
This was a complete contrast to the other family, whose 86-year-old father was dying of metastatic pancreatic cancer. He was on our service last week for hematuria, and at that time he was able to have a lucid conversation, follow commands, and eat small amounts of food. His family brought him back after he stopped eating, and now his speech is garbled and he keeps moaning. His wife and daughter were notorious throughout the cancer floor for stalking nurses and being demanding, keeping him full code despite his poor prognosis. Their biggest concern was that he was not eating, and wondering why he no longer recognized them and why his mental status has gone down the toilet. My attending explained that the patient was actively dying, and that not eating and hallucinations were part of the dying process. We then tried to bring up the idea of DNR, which the wife (and primary decision maker) seems to agree with. Her children were another story; a son I had never met until today pretty much said that doing nothing went against what the Torah stated (they're a Jewish family). The wife seems to be the most reasonable of the bunch right now, so I hope the whole family will come around soon. I'd hate to be the resident to code this poor man.
It's days like these where I'm glad that I'm not specializing in oncology after all.
Edit: The pancreatic cancer patient died two days after this post; by then, the family had made him DNR/DNI and comfort care, and he died surrounded by family.
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