Losing a patient to hospice

I lost another patient to hospice last week.

She was 49-years-old. Three years ago, she was diagnosed with stage 3 cervical cancer. She was treated with surgery and chemotherapy and went into remission and stayed there until she died. After the chemotherapy, she stayed anemic. She was weak, didn’t take care of her insulin properly and didn’t eat. Her kidneys slowly lost function because of her noncompliance, her HgA1c climbed to the teens and when she died her creatinine was 3.6. Her weight hovered around 85 pounds despite 800 mg of megesterol and 40 mg of Marinol daily.

Her metabolism was a mess. Her cholesterol was bad. She was a type I diabetic for 30 years. She had congestive heart failure, gout and malignant hypertension. She was depressed and separated for over a decade from her husband. She took enough narcotics to kill a midsized farm animal along with a stupefying amount of benzodiazepines to round out the toxic soup flowing through her. She was, however, reasonably pain free, mentally intact and capable of caring for herself as well as she ever did.

A couple of weeks ago, she was admitted to the hospital for rectal bleeding, caused by hemorrhoids from chronic constipation from the narcotic medication. After stabilizing her, the hospitalist decided that she looked terminal. She did. She was 85 pounds. She’d looked terminal for 2 years. He called in hospice, certified that she had 6 months left to live and sent her home to live out her days with her husband. Yes, that husband.

She went home, laid down in bed and never woke up again. The hospice crew discontinued all of her medications except insulin and placed her on sublingual morphine. The hospice nurse dutifully dosed her whether or not she was awake. When she stopped breathing, her family called 911 and she was brought to the hospital. Despite the usual computerized nursing triage note that stated that she was alert and oriented, she was dead on arrival. Her labs clearly showed failure to breathe as the cause of death.

In my state, hospice patients are not autopsied. By law. As a practitioner who is fairly competent at keeping patients with terminal illnesses alive past their due date while maintaining their mental function intact, physical function intact and pain controlled, the current practices of corporate hospice are a travesty. Palliative care rarely consists of removing all medications except benzodiazepines and narcotics and dosing somnolent patients until they are dead. That is euthanasia and should be called such.

Of course, neither I nor the family have any final say in this matter. Even though I treated the patient for years, the death certificate will be signed by the doctor of record, mainly because the attorney general doesn’t want to deal with me writing “homicide” as the cause of death.

“Tiredoc” is a physician.

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