Offer hospice patients a smile

Hospitals are busy places to work. The work is fast paced, and never seems to stop. For most physicians, the work ends when the work is done, or until you fall over, whichever comes first. So as a consultant, when I am seeing a patient wherein there is no longer anything that I am contributing to a patient’s care it’s routine that a physician would “sign off” the case, meaning I would not continue to see the patient on a daily basis but would be available if I were needed. Sure, I might have a good rapport with a patient, and some even tell me that I have a nice smile, but it hardly seems like a reason to continue to bill their insurance company without actually contributing any expertise. Despite how nice I think my smile is, I have yet to find an insurance company willing to pay to see it.

It’s no surprise then, that in such a busy workplace the physicians-in-training that I regularly work with would want to sign off a case as soon as possible. Unlike most of their bosses, they get paid the same no matter how many patients they see. There’s no incentive for them to see more, and if they see too many, it becomes difficult to learn anything.

So for many specialists who round on patients in a hospital, and for physicians in training in particular, the typical approach to a patient who has enrolled in hospice or decided to otherwise stop all treatments other than comfort measures, is to sign off the case.

For those patients, the thought is, most of them are waiting to be discharged home or to another facility, and have accepted that the end of life is coming. In such situations families are typically grieving, making end of life arrangements or simply trying to spend as much time with their loved one as possible before the end comes. Why would it be necessary then for a specialist or a team of physicians to enter the room of such a person, ask a plethora of unnecessary questions, perform an exam and offer meaningless platitudes like, “Hang in there! You’re doing great!”  All this to a person whose one certainty is that they’re not doing great, and they’re most definitely not going to be able to “hang in there.”

Thus my approach has been to sign off such patients, and based on what I’ve seen, it’s the approach of most other physicians as well. I had always thought that ridding people of my pestering presence at the end of their lives was the most reasonable and humane thing I could do.

But things changed for me recently, when my own father entered hospice. He was in the hospital for a few weeks, and being a physician himself, he knew the end was coming. My mother, of course found it difficult to let go. After 50 years together, who could blame her? She agreed grudgingly to hospice, but needed constant reassurance that it was the right thing to do. I remember the constant look of consternation and worry etched on her face in the days after he was enrolled in hospice (but was still in the hospital). One by one, the physicians who had convinced her that there was nothing more to be done, disappeared. The physicians who reassured her that he would be well taken care of no longer visited, at just the time that she needed their reassurance more than ever. Her face wore a look that said, “Are we doing the right thing? Are they just trying to get rid of us?” Despite having a pulmonary, critical care physician for a son, there are some things you just need to hear from your doctors, the people who have been taking care of you, the professionals who know you.

Ultimately she came to accept the inevitable, she’s a strong person, and she knew she had no choice. He passed away peacefully.

But that experience taught me to change something in my own practice. I still round with my physicians-in-training, as I always have, we still sign off those patients who are going into hospice as we always have, so the team does not needlessly pester a person at the end of their life. Instead, I walk into the room by myself, I perform no exam, I ask no medical questions. I offer them nothing but my smile. And it’s for free.

Deep Ramachandran is a pulmonary and critical care physician who blogs at CaduceusBlog.  He can be reached on Twitter @Caduceusblogger.

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  • Suzi Q 38

    A very good article on a difficult subject….dying and saying goodbye.
    I remember getting somewhat angry when certain family members were not strong enough mentally to see other dying family members.

    I had to realize that everyone is different.
    I remember a really nice doctor that called me at home as asked what to do for my father in law, who had had three major strokes and was facing dialysis. He had been ill for about 12 years, in and out of hospitals.
    Luckily for me, I was able to say, “Did you ask him?”
    The doctor was surprised that I said this, because my father in law could barely speak. He was aphasic.
    It turned out that my Father in law refused to go to dialysis.
    I viewed it as his choice. I remember going back to the nursing home and telling him that if he refused the dialysis, he would die soon.
    He softly said, “I know.”
    I appreciate that this doctor let him do what he wanted to do, as he was 82 and tired of his medically filled life.

    I noticed that before he was dying, people came around to visit.
    As he was dying, less friends and family members came.
    Why is that? Why do people mentally and physically say goodbye before the person is dead?

    I was tired of it.
    I remember deciding to have this huge party at a popular Italian restaurant. We invited everyone that we could think of, because my father in law was dying. We wrote on the card: “Celebrate Sam’s 82nd Birthday with us!” A lot of people came, and I took pictures of Sam and each guest. He had the greatest time seeing people he hadn’t seen in months or years.

    A few days later, he was back in the hospital again. He had become a “frequent flyer,” so the doctors and nurses knew him by now. I loved the doctors and nurses that cared for him. They just always asked us what we wanted to do, rather than what they thought they should do.

    I remember that I was annoyed that my husband, (his son) could not come to terms with it all, so he was working. I thought and told him:
    “Why are you working?? Your father is dying. Take some vacation time…”

    His last day on this earth, he was at the hospital again. I had dropped the kids off to school and stayed with him all morning. He seemed fine, almost happy. Aphasics can communicate very well at times. My father in law and I “spoke” about many things. The kids, his ex-wife (she had dumped him long ago, as soon as he got ill) his wife of 40 years (my husband’s mother), his sisters, his business.

    After three hours I remembered that I had to leave to visit another friend that was on Hospice and worse off than my FIL. I told him that I would be gone about two hours, but I would be back with the kids that afternoon.
    I went to visit my friend, who wanted to go home, but her husband would not allow it. I was sorry that I could not be more vocal about what she wanted. I still am. Anyway, that was the last time I saw her alive, so I am glad that I went.

    I stopped by at home to a message from FIL’s hospital that I needed to call them. No explanation. Somehow I knew.

    When my husband and I got to the hospital, it was finally time for us to cry. I had to know how he died, so I asked around for a nurse or doctor that could tell me what happened. I explained that when I left, earlier that morning, he was not in distress, and looked fine.

    The nurse told me that about 5 minutes after I left, he “coded” big time.
    they did everything that they could, including announcing that they needed to give him a blood transfusion. she said that my father in law yelled “NO!” and grabbed her arm. She told him, “If we don’t give you this blood transfusion, you will die.” She said that he was very calm and clear when he said, “That’s O.K., thank you…thank you….”

    I loved that someone told me what happened.
    I appreciated the doctors and nurses that respected his wishes.

    Do I wish that they would have stopped by more often? Sure, but I could say the same for close family members and friends.

    Thank you for your story.

    • http://www.caduceusblog.com/ Deep Ramachandran

      Thanks for your story, too. Family members react differenty I think ultimately everyone has to travel their own path and deal with it in their own way.