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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    Monday, March 03, 2003
    This weekend I did something doctors almost never do any more. Two things, actually.

    One: I made a house call. Two: I pronounced a patient dead in her own home instead of dragging her off to the hospital. (At the family's request, I might add.)

    Here's what happened. I've been following this patient since 1999, when she had the bad luck to fall and break her hip. She was admitted, the hip was surgically repaired, and she was then transferred to a skilled nursing facility for physical therapy and rehab. She hated it there, and demanded to go home. Her sister, still functional and the person who held her power of attorney, backed her up. The woman lived in a second-story apartment in West Hollywood -- she'd been there for decades -- which had no elevator access. But she deeply wanted to be in her own surroundings, and seemed disoriented in the unfamiliar facility. After many conversations, home she finally went. Since she never again was able to walk (she failed physical therapy), it was clear that getting to the doctor's office was going to be an impossibility; transportation to outpatient appointments is not covered by insurance, and there was no wheelchair access since there was no elevator. The patient literally had to be carried downstairs whenever she left the apartment, and that meant an ambulance. So, I started making house calls. I do occasionally do this, but I don't exactly advertise the fact.

    It was rather interesting, actually. This woman had traveled the world and was a gifted painter. The walls of the apartment were covered with pictures she had done over the years, as well as the occasional award from various art competitions. She frequently offered to sell me one, but I always declined. (I was secretly hoping she'd give me one, but that never happened.) On one visit I found a volume of an encyclopedia set dating from the 1930's which I skimmed through, fascinated; I wouldn't have minded having that, either. She was always willing to chat, though our conversations were limited as she was 1) stone deaf and 2) somewhat demented.

    Last spring things began to change. I had not seen my patient for several months when I got a call from her caregiver, who informed me that the patient's healthy, functional sister had fallen downstairs and broken her neck. After several months in a nursing home, she finally passed away. My patient's new power of attorney and next of kin was a relative in Alaska. About this time, my patient developed a large skin cancer on her face; this clearly required treatment. After mammoth negotiations with the family, they finally hired the ambulance - at a cost of several hundred dollars - to bring the woman to the dermatologist to get her cancer treated. Fortunately, the office treatment seemed to work well and the cancer did not recur.

    Last week I got a call from the caregiver that my patient was coughing and running a fever. I called in some antibiotics, intending to see her later in the week... but she jumped the gun and got very sick, very fast. I diagnosed pneumonia by listening to her breathing over the phone. At this point I called the relatives in Alaska and gave them the choice: either I call 911 and get her to the hospital or we keep her home with the understanding that she will almost certainly die.

    "Keep her there," they said. I agreed. So Friday night I went over to see my patient. She was shaking with rigor, covered in cardigans and blankets, and the heater was on. The apartment was like an oven. I had called in some Tylenol with codeine syrup but the caregiver hadn't been able to get it yet. The minute I saw her I knew she wouldn't last another twenty-four hours.

    "This is what we do," I told the caregiver. "When she dies, call me and I'll come over and pronounce her. Does she have funeral arrangements?"

    "Yes," was the answer, and I was shown a neatly organized file including the business card of the mortuary. Attached to the file was a Post-It: "Remove opal ring." Wow, I thought, somebody thought ahead.

    "Just one thing," I added: "If she dies in the middle of the night, please don't call me till six-thirty. I am not coming here at two o'clock in the morning to pronounce her; a couple of hours won't make any difference." I felt I had to add this, since the caregiver looked quite nervous (understandably).

    As things turned out, the patient didn't die until nine the following morning. I got the call, and back I came. She was now shrouded in the blanket and looked quite peaceful.

    "Was she comfortable last night?" I asked.

    "Oh, yes, doctor. As soon as we gave her the medicine she quieted down."

    I phoned the mortuary and gave them all the relevant information, and told the caregiver to turn off the heater. As we looked in the desk drawer for her Social Security number, I found her birth certificate which was marked "Delayed" and dated 1942; this gave me pause, as I knew my patient had been born in 1911! As I read it became clear. She was born on a farm in North Dakota, and the birth was recorded in the family Bible and sworn to as accurate by her family doctor. In that place and time, many births were probably not registered for years. Truly another era!

    As I left I felt that I had actually accomplished something. I had done something most doctors hadn't done for decades; something most doctors of my generation never will experience. More important, I had helped this woman die comfortably in her own home and had not jammed her full of intravenous tubes and lines she didn't want (she had told me many times over the last three years that she was ready to die). So, though it may sound strange, it was a really good experience.



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