One of my most treasured stories as an ED physician belongs to a lovely couple who valued quality of life. It was a routine day in the ED when an elderly woman rolled through the ambulance doors on a cold, narrow stretcher, unaccompanied by family. She was placed in bed 5, which is where we met. She was frail and her memory was poor. The EMS run sheet reported “change ...

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I loved my father. His doctor was fond of him, too. Three times we nearly lost him, and each time he pulled through, weaker, but enjoying life.  When the magical recovery didn’t materialize, it was hard to believe that this was really going to be the end -- hard for my family, and maybe harder for his doctor. No one wanted time with my dad more than I did. I wanted ...

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America is one of the sickest places on earth.  We have the best diabetic care, but the most diabetes.  First-rate cardiac care, but we are obese, hypertensive, inactive, and have high rates of heart disease.  We are the world’s standard for cancer technology, innovation and access, but we have high cancer rates even while we waste most of the money from cigarette taxes on road repairs.  At every socioeconomic level, ...

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Susan was 76 and dying at home in the days before hospice and before the use of the POLST form.  A neighbor came in the relieve Susan's daughter who went to the store.  Suddenly Susan stopped breathing and the neighbor called 911.  The medics came and, not having instructions to the contrary, did CPR and brought her to our ER unconscious and intubated.  The ER physician called me in the ...

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During a recent lunch with my daughter, a senior at the University of Maryland, she shared her frustration with a question she often receives: “So, what are your plans for next year?” She commented that while her life experiences through present day have been memorable, each stage has been predictable. Now, for the first time, she has more questions than answers. This ambivalence -- this fear of what’s ahead -- ...

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Allow me to describe a recent case and ask your opinion.  Today, you are the intake nurse at hospice and you are asked to evaluate Stan.  This gentleman has incurable cancer, but treatment would probably prolong his survival.   However, Stan has refused that treatment and been referred to you.  It is your job to decide if he is “hospice appropriate.” Why has Stan refused therapy?  It is not that he denies ...

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It was probably the most awkward question I had been asked before, and I did not have an answer. He was a middle-aged gentleman, neatly dressed -- very simple and unassuming. He blended like a lifeless statue in the waiting area. What sparked my notice of him was his accompanying robust file, crammed with familiar pink discharge slips from the ED. He was clearly what we call a “frequent flyer,” but ...

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An innovative study in JAMA Internal Medicine on surrogate decision making has profound implications for how we take care of older hospitalized patients.  The study, by Lexy Torke and colleagues at Indiana University, systematically described the involvement of surrogates in decision making for hospitalized patients. Surrogate decision making refers to the phenomenon in which someone other than the patient is making or helping to make the key medical decisions.  In older ...

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Several years ago I took care of an elderly woman in the ER.  She came in with a chief complaint of chest pain.  She came in via ambulance and by the time she got to the trauma bay she said she was feeling a little bit better.  She didn’t know she was about to die, usually people who are about to die look much worse. She looked good, all things considered.  ...

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He does not want to talk to me, that much is clear. He has had enough of doctors. He is a man of few words. His eyes do not meet mine. His coarse, calloused farmer’s hands play purposelessly with the starched white of the hospital bed sheet. The gentle hiss of his oxygen is barely heard over the hum of the city traffic below. Out of his element. “Tell me, what ...

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