Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Wednesday, December 04, 2002

    I am filling out a discharge summary for a patient at one of our SNFs (skilled nursing facilities, also known as "nursing homes"). This particular patient had end-stage cancer and died of pneumonia while at the SNF. She had a long and varied history with our group: I only acquired her as a patient about three years ago, when she decided she had tired of her original physician (whom she had been seeing for several years) and wanted a change. I think she was also annoyed with this other physician when she developed lung cancer, just as the other doctor had told her she would, after smoking for decades and refusing to quit. She was a rather difficult woman, but as seems to happen with any patient I have who is dying, I developed quite a bit of respect for her. Stubbornness is not always a bad character trait - it's helped a lot of people survive major illnesses.

    At any rate, she had a lung resection, which appeared to be curative, and did well for a few years before developing back pain about a year ago that just wouldn't go away. I thought she had a disc problem, but the MRI showed nothing. Then in April her blood tests came back markedly abnormal, and we finally diagnosed multiple myeloma. This is a cancer of the white cells in the bone marrow, similar to leukemia but not the same thing. She didn't handle chemotherapy very well, was admitted to the hospital for dehydration, generalized weakness and low potassium and calcium in September, was finally discharged and then developed pheumonia three weeks later. Her blood counts remained extremely low from the chemo and finally she was made a hospice patient and died a week later.

    So now I have to fill out this piece of paper - not an unusual task. Admitting diagnoses are listed. I have to fill in the discharge diagnoses (pretty much the same), summary of course of stay, and condition on discharge. It's this last category that suddenly gives me the mad desire to write something surreal. The fact that she's deceased is already listed at the top of the page: so what IS her condition at discharge?

    "Pretty good, considering."
    "More pleasant than when she arrived."

    And her prognosis? "Swift decomposition" comes to mind. I find myself seized by hysterical giggling... then I chicken out, quickly write "Deceased" and get the form off my desk before I can change my mind.



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