I’m sad to say that in the lull after a COVID wave we are seeing many sick people coming to the hospital. Many had treatable conditions but had poor access to specialty care, were relegated to telemedicine visits, had procedures postponed or canceled, or simply were afraid to leave the house. Advanced-stage cancers are a common occurrence.
I’ve seen this term tossed around recently and didn’t pay much attention to it. I knew that it was a problem, and had seen the first-hand effects in my resident clinic. Mostly I dealt with patients written off as having chronic pain and now dependent on large doses of opiates. Some patients would come to my office asking me to continue their already existing 240 tablet monthly Norco prescriptions. For most, my reluctance to continue that care plan led them to seek medical care elsewhere, but a select few stuck with me and I worked to address somatic complaints with non-narcotic treatments, wean them off the opiates, and address underlying psycho-social issues. Looking back, it was one of the few things I miss about clinic and developing long-term relationships with patients. Now that my practice as a Hospitalist is episodic, my personal investment in each patient feels smaller.
The White House has chimed in on this issue, in 2011 they published a plan outlining education, monitoring, and enforcement goals. More recently, the White House blasted AstraZeneca’s 5 million dollar Super Bowl ad touting a new treatment for opioid induced constipation.
Physicians have been under the magnifying glass also. Just last year a Southern California physician was convicted of murder after several overdose deaths were linked to her loose prescribing habits, which were in turn fueled by greed in a clinic making several million dollars annually.
The thing that really got me thinking was a study presented during a palliative care lecture. The premise was an elderly patient with stage 4 lung cancer and a family member at bedside insisting that the ER doc intubate her loved one. 68% of emergency physicians surveyed responded that performing the intubation would take less time than having a discussion about goals of care.
So, is the traditional bureaucratic response to this problem appropriate? Should we add more education, monitoring, enforcement, data gathering and analysis?
Practitioners in modern medical practice are already saddled with the ever-increasing complexity of electronic documentation, coding, billing, tracking, monitoring, and regulatory oversight.
We need to treat this as a SYMPTOM and not the disease. It is my opinion that physician detachment, fueled by the fire of medical bureaucracy has forced physicians into a position where patient care comes second to the care they give the chart. Time has become a commodity that physicians have to fight for. Gone are the times of the independent medical practice. The onerous burden of administration in medical practice has made us beholden to our corporate masters. Decisions about patient workloads are now in the hands of people with MBAs who know almost nothing about patient care.
This physician disengagement has led us to a place where 68% of ER docs think it would be easier to intubate the dying patient than to talk about it, even though they thought it was the wrong thing to do!
I have seen the same phenomena creep into my practice. It’s annoying for me to spend 20 minutes explaining why I think Tylenol and Ibuprofen are appropriate for my patient’s pain control after they leave the hospital. It only takes me 30 seconds to fulfill my patient’s narcotic wishes with a prescription.
I was hopeful listening to the Surgeon General’s remarks today. He talked about plans to address the opioid crisis, and his upcoming report on addiction and substance abuse:
“We’re going to stop treating addiction as a moral failing, and start seeing it for what it is: a chronic disease that must be treated with urgency and compassion…”
One of the tools that emerged to help prescribers is a PDMP, or prescription drug monitoring program. This allows providers to look up pharmacy records online and see if patients are getting narcotics from other sources. In Oregon, the program was so terribly implemented that it was almost not worth using. The time and work required to log in, search, and find what you were looking for was not worth it.
I hope that we can emphasize the importance of supporting physicians in this fight, because it is a valuable one.
I was reading this article that someone had linked on Facebook. If you don’t have time to click through the link and read the whole thing, I’ll summarize: An anecdote about a doc who leaves work in the ICU after coding two frail elderly patients back-to-back. Followed by discussion about a Canadian research survey in which they examined attitudes about end-of-life care in caregivers. Questions focused on hypothetical situations like “providing false hope to patients” and “giving aggressive care even though it is only prolonging the dying process”. The conclusion of the study and the article was that mismatch between expectations (patients and family members) and abilities (of providers) causes a moral dilemma that leads to stress and “burnout”.
Of course ICU docs and nurses were not all fairytale and moonbeams, they are in the fucking trenches! That’s like asking Guantanamo bay prisoners their opinions on America’s foreign relations policies.
Several thoughts occurred to me:
1) These conversations take time. I recently had a long conversation with a patient and his wife about end-of-life care. He was recently started on warfarin for afib, had terrible heart failure, several recent trips to the hospital and intervening SNF for rehab, and now he was back with a GI bleed. He had a stress test scheduled and was being worked up, but was exhausted, and clearly wanted to be at home on hospice. The conversation took nearly an hour to clarify his goals of care. He had a POLST form (a type of directive unique to Oregon) that said “FULL CODE”. This was completed with his PCP 2-3 years ago, before he was diagnosed with terminal systolic heart failure.
2) Doctors don’t have time. That day I had 15 patients to see in a 12 hour shift and I was already behind an hour or two on my work. I spent 90 minutes with this patient coordinating his care plan, setting up hospice, talking with discharge planners, and doing his discharge.
3) Directives don’t mean shit. Clearly, code status is a moving target, and should be re-addressed when your condition changes. I address code status with every new admission. I don’t give them options about this or that, and there is no “modified code”. If your heart stops or you stop breathing in the hospital, we are either going to do everything to save you, or nothing, and let you pass peacefully. The other hospital in town is aggressive about obtaining POLST forms and making them available in the chart. I have found these to be misleading, and often when I ask someone what their wishes are, the form does not accurately reflect them. Sure, it makes your job easier when doing an admission, but it isn’t always right.
4) People are stupid. Perhaps that’s sensationalism, but the truth is probably that physicians don’t take time to thoroughly explain these things. Often I will get an admission, and I will see the POLST form that says “DNR/Comfort Care only”. I explain to the patient that this option is essentially hospice care and means that you don’t want to be transported to the hospital when Ill, or receive any kind of medical treatment other than for comfort. Patients are often dumbfounded, even when I show them the fine print on the form that says exactly that. Many will describe the situations under which they completed the form, saying that someone in the office just gave them the form and told them to fill it out with no guidance. Sometimes they say that the doctor sent them home with it and told them to bring it back or mail it in. This article advocates for PCP involvement in end-of-life decision making, but unfortunately I don’t think that’s enough.
5) Language influences people. I have heard there is a movement to change DNR (Do Not Resuscitate) to AND (Allow Natural Death). There are many other ways to influence decisions about care, and that is likely why I see so many people check the box next to “COMFORT”. Who the fuck doesn’t want to choose comfort? That’s like having a dial in your sports car with “economy” and “BAD ASS – BITCHIN’ FAST” settings. I know where my dial would be.
There was an intern in my class who always prided herself in making all her patients DNR. It’s not hard to talk people into it if that is your agenda, Sprinkle in some colorful language like “machines” “life support” “vegetable” and you can steer someone in that direction. Yes, I have heard people say “You don’t want us breaking all your ribs doing CPR, do you?”
6) CPR does work sometimes. Below are the results of a study on the survival rates for CPR done in-hospital. That’s a 76% chance of death if you need CPR (or you could look at it as a 24% chance of revival).
Attempts—–1——-2——3 or more
(JHM 2014 Kazaure, Roman, Sosa )
7) Devil’s Advocate: There is truly value in being able to say to a loved one – “We did EVERYTHING we possibly could and your loved one died despite our best efforts. While we are jamming an ET tube into an airway full of vomitus and hearing ribs crackle and pop, looking at grey skin despite blasting in oxygen and blown pupils staring blankly…Family members see what they expect from TV drama, what popular culture has perpetuated, shocking asystole into a meaningful rhythm, and shaking your fist at the heavens, then bringing it down to the chest in a single, life-bringing compression. I think that seeing the heroic measures can help family members emotionally in some cases.
We were flying to SoCal for my step- brother’s wedding. We were late and had to run through the entire terminal. Devin stops 100 feet short of the gate and grabs his crotch: “I have to go potty!” he screams at the top of his lungs. I looked at my watch. The flight was scheduled for 6:20. It was 6:18. I yelled across the terminal: “Run, Devin, Run! You can go potty on the plane!” People began to stare. Devin didn’t budge. In the end, we made it. Southwest rocks! they waited for us!
…I heard diminished breath sounds on the left…
Here are a few mnemonics I picked up that helped me out…
HAD CLOTS: PERC Rule – Risk factors for PE
Leg Swelling – Unilateral
O2 Sat < 95%
Surgery/Trauma History – Recent
AMPLE: Important history items in trauma patients
Past Medical/Surgical History
Last Meal/Last Menstrual Period
PHAILS: Toxins that cannot be decontaminated with charcoal
DUMB BELSS: Cholinergic Toxidrome
ME DIE: Differentials for Osmolar Gap
Diuretics (Mannitol, Sorbitol)
MUDPILES: Differentials for Anion Gap Acidosis
Ethanol, Ethylene Glycol
Salicylates, Starvation, Solvents
AEIOU: Indications for dialysis
I STUMBLED: Toxins that can be removed by hemodialysis
AEIOU TIPS: Differentials for Altered Mental Status
Toxins, Trauma, Tumor
Stroke, Seizure, Shock