Posts tagged patient care

A Woman’s Life by Stonehouse.

A preceptor once told me the greatest joy of his profession was watching his patients grow. Some of them he encountered later in their life. Those whom he had the opportunity to be involved with from the very beginning however hold a special place for him. It is the good times and the bad times, the times when the first tooth erupts or the first day they walk, and the times when they first go to school or graduate from college.

That is the special privilege we have to be involved in people’s lives.

Our Deepest Condolences

One of the very first patients I had admitted was a 50-some year old father of three with a newly diagnosed colon cancer. His case read just like my father’s. Sudden changes in stool caliber. More bloating and fatigue. His wife started noticing that he looked thinner. 

By the time I had approached him in the hustle and bustle of the emergency department, the news had already been broken by the emergency physician. “You have colon cancer,” he remarked on the bluntness of that interaction. It had left him in such shock that he had little to say for most of the day. I took my time to be thorough, answering questions, gathering the history, doing the physical - his moderately ascitic belly and an enlarged liver already hinted at something more sinister. Having already been subjected to one rectal exam, he asked if I needed to double check again. I politely declined to which he breathed a great relief. 

I excused myself to review his CT scan, to get a better understanding of what was driving everything. There, on the black and white screen I saw a liver so large it seemed there would be no space for anything else in that belly. Pocked full of cysts and irregular tissue, it screamed only one conclusion: gross metastasis. 

"A few more tests," I reassured him and then he would go home, to follow up with the oncologist for further management options. I explained that the cancer had spread and that the options will be limited. He digested the news silently, his eyes flickered across the floor as he concentrated. When his wife arrived, I made sure to break the news gently. She wept regardless.

By the time I had sent him home, his belly was flatter once again, having been drained of all of the malignant fluid. The oncologist was to follow up with him within a week’s time. The prognosis was guarded but we agreed that he will be fine for at least the week.

Or so we thought.

It was a surprise to me then that not one week later, I saw him again on call in the emergency department, this time looking worse. He was confused, agitated, and grim - his skin had turned yellow. I quickly texted my attending: “Encephalopathy. Icterus.” The response was immediate: “Shit.”

Because most of the patient’s liver had been replaced by metastatic tissue, his body could no longer bear the burden. The liver had started to fail and with that, his kidneys were beginning to shut down. He was quickly transferred to the ward. 

We rediscussed code status with the family with the end drawing near and it was decided to change his care to palliative. We kept him comfortable until he died a few days later.  

Precipitous multi-organ failure is uncommon to see in someone who is still very high functioning. We never would have expected him to decline so rapidly. It was a surprise to everyone that he could be here one week and gone the next. Given his disease, there would not have been much more we could do medically.

But there are always things we could have improved on. From delivering the diagnosis with care, to advocating for a private room in his final days, to addressing the psychosocial needs of the family. These are areas that we can strive to do better. At the end of the day, this patient was not his colon cancer, he was a person. With a wife and three children. A friend to many. 

These were the pieces, in the torrent of changes that ensued on his second admission, that were lost.

"The patient died surrounded by his loved ones. We are grateful to have been involved in his care and offer our deepest condolences to his family and friends…End dictation."

16 Stories of the Patient Knowledge Gap

Some of the initial questions I ask a patient are: What brought you into the hospital? What can I do for you today? Tell me your understanding of what is going on?

These questions often sound so arbitrary and so redundant given what are generally provided to us before we even see a patient: We have reasons for referral written in the chart. We have the verbal handover from another physician. We make assumptions of affluence based on a person’s appearance.

However, it is always surprising how often there is a disconnect. For example, I once treated a patient who was a retired internal medicine doctor per the chart. Even as I spoke I realized that he was not following the medical terminology. It turned out afterwards that partly this was due to a language barrier (he was a physician in a different country), he had been retired for many years, and partly because he had some early dementia.

As the stories above illustrate, it never hurts to ask before starting.

HIV, AIDS ward closes at St. Paul Hospital due to decline in disease

The HIV/AIDS ward at St. Paul’s Hospital is closing due to a decline in the once-deadly disease, the B.C. government announced Tuesday.

“This is a proud day for British Columbians as we mark another milestone in our leadership in the fight against HIV/AIDS,” said Premier Christy Clark.

“Thanks to the dedicated efforts of the community, those at the BC Centre for Excellence in HIV/AIDS and health professionals across the province, a ward that once served those dying from AIDS, now supports those living with HIV.”

Bohemian Polypharmacy sung by Aivia, concept by Dr. James McCormack.

James McCormack is a doctor of pharmacy who is well known in Canada for his work in the Therapeutics Initiative, an independent party separate from the government and the pharmaceutical industry aiming to provide evidence-based information on drug therapy.

He is perhaps lesser known for his other side projects, one of which includes making parody music videos surrounding the world of medicine and medications.

In this video, he tackles the topic of polypharmacy.

Being a doctor was once a job with great purpose. Now it's just a business

The ‘free market’ approach to healthcare means seeing more patients in less time. We’ve lost the human connection in health reform.

This is a call to begin a spirited discussion centering on such real healthcare reform. I am not naive to the hard economic realities of healthcare delivery or how civil discussions on reforming healthcare payments need to continue. However, meaningful and lasting solutions will not be found in models that commoditize health and continue to be based on a foundation of reward and punishment alone. They will be found in models that bring back the joy of healthcare to professionals who deliver it – physicians such as me and countless others who seem to have lost the single most powerful driving force – purpose.

A disease is a whole, because one can assign it its elements; it has an aim, because one can calculate its results; it is therefore a whole placed between the limits of invasion and termination.
Audibert-Caille, 1814.
Hospice Care.

A reader asked me what hospice means. To understand hospice, I need to discuss its purpose.

Hospice care is very specific to a terminal patient. It involves palliative or ‘comfort care’ for life-limiting illness rather than curative treatments. It involves professional medical care, advanced pain and symptom management, and emotional, spiritual and practical support based on the patient’s wishes and family’s needs. In Canada, the terms ‘palliative care’ and ‘hospice care’ are often used interchangeably. The word ‘hospice’ is sometimes used to refer to a home-like place where people spend the last days or weeks of life.

I am sick of the pink. This is not pink. Pink is not breast cancer. Look at me. This is what breast cancer is.
A patient’s experience of feeling trivialized.
This has been a patient safety announcement.

This has been a patient safety announcement.