Uncertain Prognosis

The Hospitalist. 2006 August;2006(08):

August 1, 2006 | The Hospitalist

Results showed that the likelihood of a treatment resulting in mild or severe functional disability rating as acceptable increased with each month of participation in the study. More than half of the patients had prepared living wills, and these individuals were more likely to prefer death to disability, but preferences could also change. These findings suggest that even though providers, patients, and families may have already had conversations about advance care planning, a patient’s change in health status might herald the need for a new conversation.

Dr. Lamont says there are two major areas in which hospitalists can politically advocate for changes that could facilitate better advance care planning. The first is to adopt the model proposed in her study, whereby patients are queried regarding advanced directives as part of the admission history.19 Patients for whom this could be added as a new data field would include, for example, those with advanced cancer, metastatic solid tumors, relapsed leukemia, relapsed lymphoma, or with acute exacerbations of illnesses such as CHF or COPD. The second area where hospitalists could advocate for change is national healthcare policy. Like a number of others, Dr. Lamont believes CMS should begin reimbursing for high-quality end-of-life care discussions, the measures of which would be determined at both local and national levels.

Existential Issues: Alternative Ways to Communicate

David Solie, MS, PA, clinician, educator and author of How to Say It to Seniors: Closing the Communication Gap with Our Elders, was working with a patient whom Solie predicted had two to three days to live.22 Solie asked the patient’s wife whom he might call for her. She said her husband had a brother who was estranged, and though conflicted over it, the patient had vowed he would never talk to him again.

With the wife’s permission, Solie contacted the brother. When Solie came to work the next day, the brother was sitting by the patient’s bed. “As a provider,” says Solie, “it was an overwhelming experience for me. I was so caught off guard that, at this last growth phase of life, as people sort out their life and how they want to be remembered, there were chances for all kinds of reconciliations and … conclusions.”

The patient was a man in his late 40s. He’d been married and divorced and had three children in that marriage. Then he had another relationship in which he’d had two children who were quite young. The children from the second marriage were about three and six years old. His wish was to see his younger children before he died, and his mother and father and brother had hoped to help with his reconciliation—to try to get the ex-girlfriend to bring in the two children—but she had refused. So I asked, “Well, can I call?”

[I did and] I explained that he was dying and this was literally his last wish, and the next day she brought the children. It was wonderful. There was reconciliation not just with the children and the father, but with this woman. And I think he died more peacefully because of that. … I would say to other hospitalists, just use your common sense and your humanity, and also your creativity. It’s thinking outside the box. It’s not thinking in the medical model.—Eva Chittenden, MD

We had a man in his 60s who was dying of bladder cancer. He had a bowel obstruction, … a nasogastric tube, and he was terribly depressed. We spent lots of time working with him and his family, and they ended up having some good time together. It helped that once we got his nausea under control, he had a little bit of an appetite. So we asked him what he wanted to eat and he said, “peach gelato with mocha Frappuccino.” His family [felt great] because they could go out and do something. … He could eat it and taste it, and then it just got sucked back out the tube.—Eva Chittenden, MD