Saturday, September 27, 2003
When you're on staff at a hospital, one of the things you occasionally get asked to do is to "proctor" physicians who are applying to the hospital for staff membership. This generally involves reviewing a sample of their case notes and history and physical writeups. The goal of this assessment is to make sure that the physician is capable of evaluating a patient, to see whether he or she orders appropriate tests and uses the medical data to create a logical treatment plan.
Recently I was asked to proctor an internist who works for the hospital's hospice program; since the goals of hospice care are (obviously) different from the usual treatment plan, I reviewed his hospice assessment notes instead of history and physicals. In this case, the doctor was evaluating patients who had already been admitted to the hospital to assess whether they were candidates for comfort care as opposed to aggressive treatment.
So I started reading the notes. At first, I read rather by rote - diagnosis? is the med list there? the medical history, assessment, plan? All were there, yes, this guy knows what he's doing. Then the drama of these stories started to grip me: a person's entire life, encapsulated on one page. What is this person's profession? Does he/she have any family, and is the family involved in their care? What is their disease?
And the big question in the back of my mind as I read: is this person still alive? Maybe, maybe not: the most recent of the notes was dated three months back.
Not all hospice patients have dramatic diseases like cancer, I'm glad to say. I say this because I think hospice should be considered for patients other than those with imminently terminal diseases. Take this gentleman, for instance:
A 92-year-old man with generalized debility, weight loss, and declining function generally. He has chronic back pain due to disc disease and just doesn't want aggressive medical therapy anymore. Social history is telling - "daughters in conflict about care." No major findings on physical exam.
This doctor didn't change much about this man's treatment regimen except for stopping one of his medications, but the notes indicate that he spent more than half an hour counseling the patient's daughter about what she could expect toward the end of her father's life and answering her questions. That thirty-minute investment was probably exactly what was needed in this case; I hope it helped.
Then there was the case I couldn't stop thinking about.
Patient Age: 36 (36?? Holy shit!)
Chief Complaint: Metastatic Breast Cancer
This patient had recently undergone a last-ditch effort to treat her with chemotherapy, but she couldn't tolerate the side effects.
Social History: 4 children. Spanish speaking only. Family member acting as translator.
She was diagnosed with the cancer while she was pregnant. The notes indicate that she is withdrawn, depressed and worried about her kids, the youngest of whom is only one year old.
Treatment: counseling, work on treating her symptoms, get the social worker involved to help the family... there's not too much that can be done. I keep thinking about this woman and her family: that interview was six months ago and I don't know whether she's still alive.