Something Missing

Ashlin Mountjoy, MS4 at UCSD SOM, PRIME-Health Equity

There’s something missing.

Neuro
CV
Resp
FEN/GI
GU
Heme
ID
Endo
MSK/Vasc
PPx

It seems like a pretty comprehensive list. At least it’s a familiar list – the way the ICU attendings want us to present the information.

Neuro: she is minimally responsive.
CV: Her heart is stable.
Resp: Her breathing is apneic and agonal. But it’s more comfortable today than yesterday. Will start a morphine drip.
FEN/GI: She’s not eating much anymore. Do we need a feeding tube?
GU: Minimal urine output. Foley in place for urinary retention. Check.
…

Dispo:
Multiple calls placed to SNFs around the county. Can’t find a bed there, will check with another. Is the son ok with this plan? Is the monthly cost ok? Can she go to a SNF? Plan to discharge today.

Currently stable.

…

There’s something missing.

Does anyone put the pieces together? Where in the progress note is the big picture? The whole person? The person with multiple organ systems failing.

pssst…she’s dying. She’s not stable. She’s dying. She’s 102 years old. She’s comfortably dying. Dare I say she’s appropriately dying? We can let her die in peace.

No morphine drip. No feeding tube. No foley.

Something’s missing.
Perspective?
Humanism?
Compassion?

Something’s missing.

Can I fill in the gap?

I wrote this while on a Palliative Medicine rotation. I was struck reading through charts of my dying patients how little attention the broader medical field gave to the ultimate direction our patients were headed, how rarely the word death was mentioned. Sometimes we need to take a step back and look at the whole picture and accept it.

Death is a transient process

Juliet Siena Okoroh, PRIME-HEq MS4 at UCSD SOM

My patient is a 60 year male who had a motor vehicle collision into a tree.  He had an ST-segment elevation myocardial infarction and was found to have 100% occlusion of the right coronary artery and greater than 60% occlusion of the left anterior descending artery.

He is stable in the ICU, but it’s time to update family.

To myself,  “He is young and may probably survive this.”

Someone should update the family. “I will, I will.” I said.

As I walked to the door of the patient’s room to talk with the family a voice in my mind says, “Stop. Would you want to find out from a medical student if your family member was this sick in the ICU?”  Of course not.

I walk up to the resident and said, “I feel very comfortable talking with his family however given that he is critically ill I think it would be in the best interest of the patient and family to have a licensed MD discuss his clinical condition.”

The resident agreed and tells the patient’s family he is doing well and will be extubated today…

The following day I asked, “Where is my patient? He is no longer on the list.”

He passed away….

I will maintain the utter respect and dignity when communicating with the family of the critically ill.

The World is Revolving Yet…

Kavya Rao, MS3 at UCSD SOM

 

“The world is revolving yet.” 

 

This was a quote from DH, an 87 year old man with Alzheimer’s, in response to my request of him to write down any complete sentence as part of his MMSE. He wrote this down with trembling hands while I was busy feeling sorry for him as well as his prognosis. 

 

After I had read the paper, I stared at him incredulously. He winked and grinned at me, as if we were sharing some delicious joke, some big secret about life. It became clear to me that brave, beautiful, funny DH was – at least for now – still very much alive.