Discharging the Drug Seeker

When I went to discharge my pain-seeking patient yesterday, I picked up her chart and saw a sealed envelope taped to the chart addressed to me. "For Dr. ____ Only" it read. I wasn't sure what to expect, but what I pulled out were four stapled sheets of notebook paper, both front and back filled out, and consisted mainly of a list of grievances that the patient felt had been committed against her since her thoracotomy two weeks ago. Mostly, she was furious that I'd called an "MD" (her name for the pain specialist) who was "disrespectful" and "power hungry" and did nothing to try to help her pain (as she believes a pain specialist's goal is the comfort of the patient). She also described the increased "suffering" she endured from not being able to talk to me over the weekend (it was my weekend off) and accused me of forgetting our "good relationship built on trust." She felt I put my trust in the wrong person (the pain specialist), and in her words, "I suffered since you left me and in my book and most others that is not very thoughtful practice." My mental response when I read that part: What. The. F***.

Maybe she thought that she was speaking to me as one health professional  to another (since she used to be a NP, apparently) and used plenty of medical terminology in her letter to emphasize that, but to me this seemed more like the ranting of a crazy person. I don't blame her for writing a letter and putting all her thoughts on feelings on paper; hadn't I done the same throughout junior high, high school, and college when I kept a journal? But this was definitely something else. She also included a list of medications she needed for home, including Valtrex (which she didn't even NEED anymore since she got 10 days of Valtrex in the hospital for shingles) and my favorite, "Dilaudid 2 mg IV q3." She claimed that she had received IV Dilaudid at home in the past, but I find that extremely doubtful. I vented to several of my colleagues about what to do, and they told me not to give her narcs at all and get her out. The problem: I knew this woman, and if I didn't send her home with scripts for narcotics, she'd throw a fit, and that's the last thing I wanted. My number one goal was to get her OUT.

When I went into her room to see her (with the nurse, of course), she initially didn't make eye contact me and said, "Did you read my note?" I said yes, then added that I'm sorry I wasn't there over the weekend and added, "It was my weekend off." She said that she understood that doctors need time off, then went on about how offended she was by the pain specialist when he tried to cut her off IV meds. I made no move to be friendly during her one-sided complaining; I kept my arms crossed like I meant business and I think she read into that. When she asked if I'd be writing her all the medications she requested, I said, "I'll take care of it." She was particularly insistent about getting oral Dilaudid, saying that she needed it for "several weeks" but I wasn't about to do that. I wrote her for a two week supply of pain medications; if she wants more, she'll either have to go to the ER or go to the pain specialist, which I doubt she'll do since she hated his guts. She even asked if she could have an extra dose of IV Dilaudid before she left, but I pretended not to hear her and the nurse quickly removed her IV and said it was time to go. Fortunately, the patient was mentally ready to leave, and she left without a fight.

Today a lot of us in the nurses' station couldn't stop talking about how much better things were now that she's gone. I, for one, am more cheerful and don't dread that particular floor anymore. I did put her note in the chart and it has been scanned and is part of her permanent record. If she ever returns with drug seeking behavior or tries to get me in trouble, I'll gladly show her note to the CEO or whoever else wants to see. Let them read that note and see exactly what state of mind she's in. She's batshit crazy, and I can only hope that I'm never on call whenever she returns. The two weeks she was my patient, I felt like my soul was being sucked out day by day. Now I can get some of my sanity back.

Master Manipulator

One of the biggest challenges I've found with being an attending is learning to deal with drug-seeking patients. I had plenty of those throughout residency, but I was protected because I didn't have a DEA number and therefore couldn't write prescriptions for narcotics. If they needed pain meds, I just said, "Talk to my attending" and left it to the attending to decide whether or not to write for narcs. Now I am the attending, and I have to deal with these narc seekers directly. Sometimes it goes well, other times not.

For the past two weeks I've had to take care of a patient (who, incidentally, used to work as a nurse practitioner before she was injured in the line of duty in Iraq) who was transferred to our hospital for a thoracotomy for a persistent pleural effusion (no CT surg at the other hospital). I'd heard from the EMS reports that the patient was a big-time drug seeker and that the other hospital was glad to be rid of her. That should have been the first indication that the patient would be difficult. She had the VATS and had two chest tubes placed. Most people are simply placed on a PCA Dilaudid until the pain improved, but not her. In addition to the PCA Dilaudid (which she rarely used), she was also getting 1-2 mg Dilaudid IV q3 prn, and then she "begged" the CT surgery team to give her a basal dose on the PCA since she was waking up in pain. There were many times when I tried to wean her off the PCA (at least the bolus), but she'd always cut me off, saying that it was "unethical" for a patient to be in the hospital in so much pain and that she needed to be comfortable so that she can undergo physical therapy and do what she could to get better.

Finally last Monday her chest tubes were pulled, and I can reinitiated plans to wean her off Dilaudid. The plan was to discharge her on Friday. She didn't really make a fuss when I stopped the bolus and then the PCA (she wasn't pressing the button much by then anyhow), but when I tried to stop the q3 Dilaudid, she argued with me, saying that she "needed" the Dilaudid while she was in the hospital. "When you're ready to let me go, I'll be fine with the pills," she said, "but while I'm here, I want to be as comfortable as I can be." Any attempts I had to try to wean her would lead to 30-45 minute conversations/arguments which I don't have time for, so previously I let her have her own way. Then the patient said she didn't want to go home on Friday b/c she didn't feel "safe" being alone especially with the Fortune-1 race in town, and that she was going to go home on Monday instead because "my insurance will cover my stay." That was the last straw. Finally I took a partner's advice and asked a pain specialist to see her. He prescribed her with a Fentanyl patch, discontinued her IV Dilaudid, and cleared her for discharge on Friday. I was told that right after he left her room, she frantically called her nurse asking to speak with me. Fortunately the nurses protected me and told her I was gone for the day, and I did all her discharge paperwork in hopes that one of my partners (who was covering for me since I took Friday off) would be able to discharge her in my absence.

It didn't work. I'd told my partner to write the discharge order and be done with it, but instead she got sucked into another 45 minute debate as my patient listed all the reasons she couldn't go home on Friday, but then agreed to go home on Saturday. See, that was crafty on her part, because Home Health doesn't go to patient's homes on weekends, and the patient needed Home Health. In agreeing to leave the hospital on Saturday, then saying on Saturday that she can't go home until Monday because that's when home health shows up, she essentially bought herself a weekend stay. I was pretty furious when I called her nurse and got this info; I was hoping not to have to deal with her this coming Monday.

But it looks like I will have to deal with her on Monday, but I'll be damned if I let her manipulate me into staying another day longer. It's pathetic to see how a former medical professional like herself became a drug-seeking manipulator, but I'm through with playing her games. She goes Monday, no matter what.

A Day in the Life...

Now that I've been working for over a month, life has settled into something of a comfortable routine. In some way, since the hospitalists work independently of each other (unless we're on call), I am my own boss. I set my own hours, decide when to come to the hospital and which patients to see first, and leave when my work is done. Most days I come to work between 6:30am - 7:00am in hopes of finishing earlier (so that I can get out of the hospital sooner), but if I worked a 5-10pm call shift the night before and didn't leave the hospital until 11:30pm, then I'll usually come to work later, like 7:30a.m. (try to give myself at least 5.5-6 hrs of sleep a night). Or if I need to be somewhere by 4 pm and I have 15 patients to see, I'll come at 6:00 a.m. to give me plenty of time to work. No one ever yells at me for being late, and no one tells me how to practice medicine. I just hope that I know what I'm doing.

In the mornings, depending on how high or low my census is, I can usually expect to get some extra patients who were admitted overnight. Or, if one or two of my partners has decided to take the day off, their patient lists are split amongst the rest of us. The only rule regarding taking days off is that 10 hospitalists have to be present on any given day, so some partners use this to their advantage (i.e. take every Friday off). I once took a day off to attend hospital orientation, but since I got out in 4 hours, I ended up taking back my patients and working a regular day anyway. This is why I try to come to the hospital early; yesterday I ended up with four new patients on top of the others I already had. My "desired" patient cap is 15, so as long as my census is less than 15, I can almost always expect to get new patients every morning.

The general rule is to see the ICU and IMC patients first, and since the IMC is on the top floor of the hospital, proceed with gravity rounds. I usually stick to this rule, but there are times where I will skip a floor (i.e. if the patient's a rock) and go to a different floor where I know I have pending discharges to do. We try to discharge patients as early as possible, and those take up a LOT of time (paperwork plus dictations). I once spent almost an hour dictating a patient who'd been here for a month and miraculously survived everything that got thrown at him (GI bleed with simultaneous MI, gastrectomy, post-op CVA, etc), and that delayed time in seeing other patients. On a good day I can see 4-5 patients in an hour if they're not too complicated. The ICU/IMC patients usually take up a good 30-40 minutes per visit.

Food is free for physicians in the hospital (awesome perk!), and is usually not that bad. I've even stopped making my own breakfast of oatmeal and eggs b/c I can get the same at the hospital (plus extra fruit and bacon I wouldn't otherwise eat....) The menu has both healthy and greasy options, though my biggest weakness so far is helping myself to a chocolate chip cookie for dessert at lunch. I never ate cookies in residency b/c I had to pay for them (which I refused to do), but when the cookie is free, then all that goes out the window. So needless to say I've gained some weight. =P

Overall, more good days than bad on this job. Can't complain about that one =)

Loss of a Classmate II

This afternoon I checked Facebook after work to learn that another of my med school classmates, John M., died earlier today after a battle with cancer. It seems so surreal that less than four years after our class lost Kasha, now we've lost John, too. I'd be lying if I said John and I were friends in med school; we sat in different parts of the classroom and never did any rotations together. My six weeks in Corpus Christi was the closest I got to spending time with John and the rest of the "Corpus crew;" I still have pictures of us TCOMers hanging out at Sue's July 4th BBQ or Utopia (which is now closed) for happy hour. When I look back, he was probably one of the shining stars in the class, because while I've forgotten the names of classmates with whom I barely interacted, I've never forgotten him.

One of the things I remember most about John is his smile. He had a great sense of humor, and there was something about his smile that made me want to smile as well. Once during our first year, Erwin was showing me the recently-released "Ms. New Booty" music video (I am not making this up) during a break in class, and John, who was sitting several rows behind us, saw what we were watching and started laughing, too. I was initially mortified, but soon realized that John was laughing with us, not at us. His laughter was contagious, and he was no stranger to poking fun at himself on occasion. The too-small Batman and Robin costumes that he and Tony wore to the 2005 Halloween party attest to that.

I didn't know John had metastatic cancer until several months ago, when I heard the news through the TCOM grapevine. I was told that not many people knew of his diagnosis, and out of respect for his privacy I kept the news to myself. I can still remember how my mother didn't want others to know when she was diagnosed with breast cancer, preferring to go on with her life and not let cancer knock her down. John, as it turns out, was no different; after his diagnosis he continued working at his residency for quite some time. It's a question I've asked myself before: if I was diagnosed with a deadly illness during residency, what would I do with the time I had left? The selfless doctor in me would probably wish to continue my training so that I can become the best doctor I can be before I depart this world, but the larger, selfish part of me would want to quit residency, spend time with family, and travel to Japan, Paris, and other places I've yet to see. So when I heard what John was doing, I couldn't help but admire his strength and courage.

Even if I didn't know John had cancer, I could guess from his Facebook pictures that something was different. He'd lost his hair, and his face had that hollow look that I'd seen so often in my cancer patients. The only difference: in his pictures he was smiling. There were times where I thought about writing on his wall to tell him I was thinking of him, but never did, as most likely I wasn't even supposed to know he was sick. News of his death today still came as a shock to me, as it tears my heart whenever young people with their whole lives ahead of them have their lives cut short.

Goodbye, John. You will be missed.

Now the Real Work Begins

I've been working as a hospitalist for two weeks now, and I think I've settled in pretty well. During the first week I bumped my cap up from 5 to 12, and more recently bumped it up to 14. The most number of patients I've had to see so far on any given day is 12, but even that was manageable. The real challenge is going to be the weekend, when each hospitalist has to see 25-30 patients; I'm guessing I'll be at the hospital until 5 pm. The other hospitalists in the group have been very helpful and supportive in giving advice or providing me with contact information for the various specialists in the hospital. Probably one of the best parts of being an attending is that no specialist will give me crap for a consult. A surg-onc didn't mind the prospect of doing a Whipple on a Saturday when I told him about a pt with resectable ampullary CA. I had to consult one heme-onc attending twice in one day because her number was the only one I had, causing her to stay at the hospital until 7-8 pm, but when I met her in person she was gracious and thanked me for the consults. I was giving her business, after all; one of the consults was for a newly diagnosed colon CA.

One of the oncologists commented that being a hospitalist at SAMC is not all that different from residency, and in ways she is right. Because we don't do the 7-on, 7-off schedule, we can leave the hospital as soon as our work is done on non-call days (for me, that's probably around 2 pm for 10 pts). That means a certain number of people have to stay later at the hospital each day to take call and do admissions. There's two people on call between 12-5 pm, two people between 5-10 pm, and then a designated night float who does all overnight admissions. On average I take call twice a week. Some people will even volunteer to do extra calls so that they get more patients (apparently H&P's bring in the most money), a concept that's still foreign to me. I only need to support myself, and was able to do so on a resident's salary, so right now I don't feel the urge to work extra shifts for extra money. Of course, if one of the partners becomes ill and needs someone to cover their shift, I'll volunteer as long as I don't have to do two calls in a row.

This sort of schedule works well for me because I like leaving the hospital as soon as my work is done (I always hated the 7am - 7pm shifts and vice versa when doing triage/MAR in residency), and I wouldn't know what to do with myself if I had seven days off. I suppose I could moonlight if I wanted to; one of the hospitalists said that he used to work at a 7-on, 7-off hospital and would moonlight on his weeks off for extra money. Plus, at least in Austin, there's a whole lot you can do for your week off. Personally I think I'd get burned out too quickly if I had to work seven 12-hr shifts in a row that involved both admitting new patients and taking care of old ones. At least now I don't have to admit everyday.

My two week adjustment period is over. Starting tomorrow, I'll be working almost every other weekend, taking call 2-3 times a week, and seeing well more than 10 pts a day (which I've just become comfortable with). Weekends have become more precious than ever. I never did like working black weekends in residency, but that's part of the package in this hospital. As long as I make my golden weekends worthwhile, then I hope things will be okay.

First Day of Work: Plagued by Doubts

Yesterday was supposed to be my first day on the job, but since I wasn't assigned a user name for computer log-ins until the morning (apparently someone forgot to sign my credentialing papers on Friday that would have allowed me to start work on time), I had an extra afternoon off. My morning, instead, was spent familiarizing myself with the layout of patient charts and learning how to use the EMR at this hospital. Some of the attendings suggested that I could shadow someone for the day, but I respectfully declined. These guys had patients to see; I didn't want to take away from that time by having them babysit me.

Back in February I accepted a contract from a hospitalist group that works in various hospitals around the city; I would be spending most of my time in one particular hospital, the SAMC. The SAMC has only 200 beds, but our group cares for the majority of the patients. There are about 15-16 hospitalists at SAMC, and each one sees 12-15 patients daily on average. Fortunately for me, the "pod leader" of the hospitalists was going to start me off with 5 patients, and no call for the rest of September until I learn to do things around the hospital. That's more than kind. One of the hospitalists (who shares my last name) made a point of taking me to different nursing stations and introducing me to the nurses, for my sake as well as his (i.e. please specify which Dr. ____ you need, the male or the female). Most of the nurses knew of my arrival and were both welcoming and happy to see me. "You guys just keep hiring!" one charge nurse commented; before I arrived, another woman started in July, and several people started working in February.

After 2.5 months of "freedom" from medicine (1.5 of which was devoted to boards), I was eager to get back to being a doctor again. Five patients doesn't sound like a lot, but on the first day, I probably averaged 45-60 minutes per patient because I wanted to be thorough. The safety net I had as a resident is gone; there is no attending to tell me what to do because I am the attending now. Sure, I can ask my more experienced colleagues for help, but I need to show them I can stand on my own two feet. Fortunately I was given relatively easy cases (nothing in the MICU): three chest pain rule-outs (one went to cath, two got stress tests), one rhabdo, and one N/V with elevated troponins.

Even though I was pretty sure I knew how to take care of my patients, even after I went home, a lot of things nagged at me. My rhabdo guy also presented with sky-high LFTs; was it safe to attribute the LFTs only to the rhabdo when the RUQ U/S just showed a fatty liver? At the hospital I was able to justify not getting GI involved; at home, I wonder if I am doing the right thing. I also noticed his chloride was creeping up, possibly due to all the NaCl I'm giving him, but how high is too high? One attending suggested I treat him with a bicarb drip because his CK exceeded 50,000, but his bicarb and creatinine were normal and CK was falling with fluids so I chose not to do so. Then one of the nephrologists called my cell expressing concern that her patient was having worsening back pain and may need an MRI (despite negative films). A cardiologist paged me at 6 pm to let me know one of my chest pains had a negative stress test; had this been hours earlier, I might have discharged her. Another chest pain just needed his cardiologist's input as to whether he can go home; I asked the nurse to call me once they had an answer; they never did. I just know I'll feel really bad tomorrow morning if I find that one of the on-call partners had to discharge my patient for me.

This is probably the toughest part of being a brand new hospitalist fresh out of residency: even after I go home, I find myself worrying about whether or not I did the right thing for my patients. Some of this may be attributed to lack of confidence; I was never the smartest resident in my class, but I tried to make up for it with being hardworking and responsible. I imagine it'll take some time before I'm truly comfortable being a full-time hospitalist, but for now, I'm willing to take things day by day.

Rising from the Ashes

Last weekend I spent the last weekend of my vacation in New York City, a place that I've visited several times since moving to Philly but never really in its entirety. Prior to residency, I had only been to New York once, during my junior year of high school. At that time, the World Trade Center was still standing, though I only saw it from the windows of a harbor cruise ship. My next visit to the city was in 2009, during my intern year, because my college roommate was working in NY at the time and invited me for the weekend. Since then, I have tried to make a day trip to New York at least every 2 months, each time going somewhere/doing something different to check off my NY bucket list. In my visits to NY, I've been to the Empire State Building, watched "Spiderman: Turn off the Dark" on Broadway (twice!), ridden a water taxi to the Statue of Liberty (when my parents came to visit), ate ramen at Ippudo, and been to both the Metropolitan Museum of Art and the Museum of Modern Art (MoMA). One place I had never visited up close, however, was Ground Zero.

The first time I laid eyes on Ground Zero was from a plane in 2009, when I flew from Rochester to La Guardia Airport en route to Philly. I'd always been fascinated about the events of September 11, 2001, particularly the stories of survivors who escaped the carnage and the firefighters/policemen/civilians who gave their lives in the end to help others escape. I rarely ever went to Lower Manhattan (where Ground Zero was), as most of my time in NY was spent in Midtown, but on the rare occasions I did go to Lower Manhattan, I captured pictures of work in progress.

This was taken in summer of 2011. And nearly one year later, it has reached its full height.

The 9-11 museum hasn't opened yet (will likely open on September 11, 2012), but the Memorial was open to visitors. Admission was free but passes must be reserved in advance, so I booked my ticket online and joined the huge throng of visitors from all around the world to view the memorial.

The layout of the  Memorial had two pools in the footprints of the Twin Towers (the South Tower waterfall and the unfinished Museum in the background are seen above). I tried to imagine what the towers must have looked like up close in 2001, but could not. There were so many names inscribed along the wall surrounding the pools, with several reading "____ and her unborn child" for the women who had been pregnant when they died. All those names were a grim reminder of all that was lost. Amazingly, at the North Pool I spotted a rainbow hidden in the water.

Then there was the "Survivor Tree," a pear tree that once stood outside the Twin Towers and was reduced to a stump after the attacks. Miraculously, it survived and was taken to a nursery where it grew new branches and eventually grew more than 30 feet tall. Recently it was moved back to the Memorial, where it is held in place with support wires. Up close, you can see the original stump pulled from the rubble of the towers and the newer branches that grew from that stump after it was rescued. Truly a survivor.

I feel fortunate to have been able to visit the Memorial and pay my respects to the ones who died on September 11, 2001. Someday when the museum opens, I will definitely be back again.

Killing Me Slowly

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.

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 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.