I enter the patient’s bedroom after a brief chat with the daughter who is sitting outside.
“Mom had diarrhea … she’s also got dementia … ”
“Who are you?”
“Hello, Auntie .. I’m doctor .. I came to check on you … …”
“Go away. There’s nothing wrong with me. I don’t want to see a doctor.”
“OK .. ”
I walk out of the patient’s room, and into the living room – Out of sight now.
3 minutes later, I walk into the patient’s room again
“Who are you?”
“Hello, Auntie .. I’m Jane’s friend … I came to visit … have you eaten?”
“Yes. I have”
“Was the food nice and does your tummy feel full?”
I reach out to feel the ABDOMEN – Soft, non-tender
The rest of the physical examination performed in 5 parts, getting history from the daughter outside the bedroom in between ….
Previously I posted about a patient who had symptoms of giddiness and vertigo, but turned out to have a heart attack instead.
This time, I saw a patient with 3 episodes of giddiness over one week. He also experienced cold sweat during these episodes. Additionally, he felt physically tired – so much so that he could not walk his usual 2km – he had to stop after half the distance.
When I saw him, he was not terribly distressed but was drenched in sweat. Worried that it might be a heart attack, I advised him to go to the emergency department for further evaluation.
Turns out it wasn’t a heart attack – his X-Ray showed some signs of a chest infection. He had not complained of fever, cough, or breathlessness; his description was more of fatigue – a sense of tiredness and feeling weak. Good thing we had the investigations done for him…
Three patients in a row today with low blood pressure. For sure, they needed to be hospitalized; none of them (or their families) wanted to go. You can see that they understood the gravity of the situation, they nod their heads at the explanations – bleeding from the gut, possible malignancy, infection (sepsis). Their faces did not show much distress or worry. It looked like they had already made up their minds.
I could understand that the elderly lady vomiting blood was reluctant to go because it was near the all important new year holiday season. But I didn’t understand why the lady with severe anemia (of unknown cause) did not want to get it sorted out. The family of the patient* with sepsis decided to keep their options open – wanting to observe the situation and possibly reconsider hospitalization.
With their minds more or less fixed on not going to hospital (that’s why they got me in for a housecall in the first place), convincing them otherwise is very hard. Supporting them with what they want is all that can be done. Injections to stop vomiting (blood), anti-acid medications for presumed gastric bleeding, antibiotics for infection, etc.
I’m not sure what their outcomes might be – whether the families might convince patients to eventually visit the hospital. But we can only do so much. Outcomes can’t be controlled.
*the patient had dementia, and so the family had to decide for him
These days, she’s not been able to communicate as much and doesn’t even swallow her food properly. She looked interested in our conversation, but it was unlikely that she knew what the discussion was about. But still, her expressions followed the tone of our conversation – flowing between curiosity, and concern.
At the table nearby, her daughter was relating an episode about how she felt so guilty when another doctor told her that not using tube-feeding for her mother was like “starving her to death”. At the moment, we’re hardly near that stage. But the daughter and family already know that drastically reduced food intake is an eventual consequence of the decline from dementia.
We’d already gone through options for care, including whether patients might benefit from tube-feeding. The facts objectively laid out and clear. She thought she had it all planned out and decided, until that encounter. Would have been easy if humans just relied on being rational and logical. Now she’s unsure if she’s doing the right thing, with some guilt lingering.
Being judged on what choice (tube feeding) one makes for his or her parent is never helpful; maybe even harmful. Instead, understanding that choices are always made in contexts that we can never fully appreciate is wiser. Accepting that there are very different choices which can be made, not necessarily a right or wrong choice is good enough. Just choices, and supporting the patient and family – whatever the choice.
link to NY Times article on tube feeding
American Geriatrics Society – position statement on tube feeding in advanced dementia
She passed away in 36 hours, quietly and peacefully at home. The atmosphere in the home was also quiet and peaceful. No panic, no rush, .. just doing what is required. In fact, there was a sense of relief that this happened now, and not during the Chinese New Year season.
The day before, I was called in to see her as she had deteriorated – she had stopped eating and her breathing pattern had changed. She was still alert, opening her eyes and even moving her limbs a little; she reacted when she could hear her husband in the hall.
Her family already knew that her death was impending but needed a professional opinion to confirm this to be the case. Once this was provided, the necessary care and arrangements could follow. There was not much in the way of medical care, as there were no distressing symptoms. It was more a question of knowing and preparing.
Supporting the patient and family in this way is an important role for healthcare professionals. As professionals we often feel the need to do something – prescribe medication, intervene, etc. That is still necessary in many cases, but for this patient (and the family) having the prognosis confirmed was what really mattered.
Physicians don’t take the diagnosis of cancer lightly. In the usual case, thorough investigations are done – blood tests, scans, biopsies, etc. before the diagnosis is made. This is so that subsequent treatment can be planned and optimized for the patient. However, this is not always possible for home care patients, nor is it always necessary.
Two recent patients come to mind.The first patient was in her mid-nineties with a breast lump and enlarged liver – found by examining the patient. She was referred to hospice care and passed away within 3 months. The second patient (also about ninety years old) had a growing patch of discoloration in her mouth (previously biopsied 1 year ago and told no cancer). Similarly, no further investigation was made and she received palliative care at home before passing away in a matter of months.
These patients certainly did not want further investigations to confirm the diagnosis – it was enough to have examined the patient. In fact, home clinical assessment and close follow-up was able to provide a more accurate picture of the second patient’s condition. Neither did they need a hard ‘technical’ diagnosis to guide further treatment – they had wanted to remain comfortable and receive palliative care at home.
In the past when hospital based care was more visible than home care, this way of managing patients (without a ‘hard’ diagnosis) might have been perceived as inappropriate or less than a reasonable standard. Some physicians may have felt uncomfortable about not having a firm diagnosis in these cases.
But this is all a matter of context. It is about understanding the patient’s situation and needs, rather than having to fulfill technical or organizational needs (and definitions). Going back to basics – hands on examination of patients – may be just the thing that is needed and that provides patients the feeling that they are cared for.
Few days ago, I saw an elderly lady with chest pain, leg swelling and irregular heartbeats. She was staying at home with a helper, the rest of her family being away overseas. Being a foreigner, she was worried about going to the hospital because she wasn’t sure how to handle the paperwork, administration, etc.
Fortunately, her neighbor was at hand to help. In fact, it was this caring neighbor that had arranged for me to visit the elderly lady. She was prepared to help arrange transport, etc. to get the patient to hospital. In this case, she would be getting the help of yet another neighbor!
We eventually persuaded her to be transferred to the hospital where she was then admitted. It was good to see such community spirit, with neighbors pitching in to help each other. One wonders if the patient would have deteriorated, were there no neighbors to help…
Having to be admitted to hospital is not something we wish for, certainly not for elderly parents. A patient I saw was recently admitted to a hospital following a first episode of seizures (fits).
The elderly man had a history of dementia, hypertension, high cholesterol and heart disease. His children shared their experiences with me:
- My father came home in a worse condition than when he was admitted. Before, he was able to walk with some help but is largely bed-bound now. Worse, he now has a urine catheter in place.
- The hospital doctors had no idea what caused the seizures, despite doing tons of investigations. Then they started him on so many new medications with side effects.
- Different doctors at the hospital kept asking the same questions over and over again, and it seemed like they were experimenting with different drugs on my father.
- I do not wish for my father to go back to hospital ever again.
Actually, the above comments are quite commonly heard from patients and their families. As a healthcare professional, I fully understand why the hospital staff needed to do what they did. For example, the patients’ urinary problems were probably pre-existing but undetected until this admission; he required a long term urinary catheter, as he continued to retain large volumes of urine.
What the patients and families needed was to hear the explanations clearly – good patient communication. But I also know that his is not easy to do in a hospital where staff are clearly very busy and time is limited. This is where primary care physicians like myself can be of help. Perhaps taking some time to listen, and explain what went on in hospital.
This task of listening and explaining may seem simple, but it can have clinical impact down the road. If the patient and family understands the situation, it may temper their reluctance to be admitted again if a real need arises.
I recall a case some years ago, where I was called to certify the death of an elderly lady who was bedridden, with a previous history of stroke. She apparently passed away peacefully at home but there was a forehead bruise from a recent fall (this was made known to me by her family). …
Doctors can certify the death of patients who pass away at home if the cause of death is known, AND if the death is due to natural causes.
For patients who are have sufficient documentation regarding their medical history* (e.g. medical reports, discharge summaries, lab tests), certifying the cause of death can be quite straightforward. For example, patients under home hospice services generally have documentation of their condition in a file kept at home. In this case, one can work out and make an assessment of the likely cause of death.
The situation under which the patient passes away is also important, in order to decide if the death at home can be certified. Unnatural causes of death such as due to falls, injury (trauma), traffic accidents, medication errors, etc. cannot be certified, and requires the coroner to take up the case. There are clearly serious medico-legal implications for deaths occurring under these circumstances.
… I declined to certify the death of the above patient, explaining the proper procedures to the family. The family was understanding of the situation and agreed that it was best to inform the police in order that proper protocol be followed…
As noted in a previous post, pressure sores are a common problem I see on housecalls. In order to monitor pressure sores, it is necessary to assess their severity (An excellent description here from WebMD) as well as keep records of the progress. In my experience managing patients at home, it can be useful if family or caregivers are able to record the progress of pressure sores with photos.Mobile apps can be a useful tool for such monitoring purposes. The IUVO app was designed by some colleagues and myself in order to facilitate this.