The difficult conversations physicians have with patients

A 60-year-old lady came for follow-up after a recent stay in the hospital. She was diabetic — horribly uncontrolled — the result of which was that she had already been on dialysis for four years. She ended up in the emergency room with chest pain. Diabetic patients are at higher risk than the general population of having heart attacks.

She underwent studies to evaluate for blockages in her heart. The cardiologist found a significant blockage, but a stent could not be placed because of tricky anatomy. She was started on medicines for the blockage and for blood pressure.

At first glance on meeting her, I would never have guessed that she was a lady who had gotten sick. She was incredibly put-together with a vibrant personality. Her hair was dyed and styled. She wore makeup and red lipstick. Her clothes were colorful and matched her jewelry. Her shiny, crimson nails matched her lips.

I asked her how she was feeling.

“Fine,” she said.

I asked her if she was experiencing any more chest pain.

“Nope.”

I reviewed her hospital course with her: she had chest pain, and the cardiologist found blockage in one of her coronary arteries but couldn’t place a stent because it would have technically been difficult. So her heart disease is being managed as best as possible with medications.

“I don’t like taking medications.”

This is one of the most frequent complaints I hear. Truthfully I personally will let a headache persist before succumbing to the pain and taking Acetaminophen. But we are not talking about a headache. We are talking about uncontrolled diabetes as a risk factor for heart disease. Heart disease is still the number one killer in the U.S.

I advised her that many people shared her sentiments. But now these medicines were sustaining her life. She nodded and said she understood.

I inquired about her diabetes control.

“Oh, doctor, I’m the worst diabetic. I don’t check my sugars. I hate pricking myself.”

I asked her if she took her insulin regularly. She responded that she takes it “sometimes.”

I asked her how dialysis was going.

“It’s OK. I just hate it. I missed the last session and had to go back to the hospital to get it.”

For patients whose kidneys have failed, hemodialysis is scheduled three times/week to clean toxins from the blood and normalize electrolytes. Electrolyte imbalances can be fatal.

I asked her why she missed dialysis.

“My cousins were visiting from out of town, and we went out for karaoke.”

I asked her why she prioritized karaoke over dialysis.

She wrinkled her nose at me and sighed.

“Doctor, I really hate dialysis. I hate feeling confined by being sick.”

As a physician, I am now faced with a dilemma. This lady has uncontrolled diabetes, the result of which is heart disease and kidney disease. Her kidneys have already failed because of bad diabetes. If she stays off track, she remains high risk for heart attacks, strokes, vascular disease, and blindness.

In an attempt to gauge her support system, I asked her who else in her family suffers from diabetes. She tells me that 60 percent of her siblings suffer from diabetes. One brother apparently is frequently in and out of the ER with life-threateningly high sugars.

I realize I have no angle. I can’t caution her about heart disease because she already has it. I can’t caution her about kidney disease because she already has it. None of her siblings are good examples to follow. I am not confident that she is motivated to get her diabetes under control. She is also telling me, indirectly, that the process of “living,” (i.e., blood tests, dialysis, finger pricking, insulin injections, and medicines) is causing her suffering as it’s not compatible with how she would like to live her life. I can only do so much. I definitely cannot adjust her insulin doses if she isn’t checking her sugars.

I am rarely this blunt. I established eye contact with her and confronted her:

“What I am hearing is that you don’t like taking medications, you don’t like pricking your fingers and don’t like dialysis. Do you want to live?”

She looked at me, puzzled. I definitely had her attention.

I asked her if she would want to be revived if she were to stop breathing or her heart were to stop beating.

It took that level of introspection for me to get through to her. Her eyes welled up, and tears spilled into her cheeks.

She said she definitely does not desire heroic measures. BUT —

“I love my grandkids. They live with me, and I love chatting with them and having Sunday night dinners. They are the light of my life.”

“OK. So, it seems you have joy and find value in your life.”

“Oh, yes!”

“So, how does it make you and your grandkids feel when you end up in the hospital away from your grandkids because of a missed dialysis session? Or because you had chest pains?”

She was silent.

I allowed her to feel whatever she was feeling. I sat by her side holding a box of tissues. She cried for over half an hour. When she was done, she said, “Nobody ever explained it like that to her” and she thanked me for the heart-to-heart. I hugged her and told her I had faith in her. My nurse later told me that the patient reflected that I “went deep and peeled off the layers.”

Being a physician means providing quality evidence-based care. But it also means reading people and helping them overcome obstacles to health. It means being able and willing to have difficult conversations. Lastly, it means having heart, empathy, and compassion because, in the end, we are all humans.

Uzma Khan is a hospitalist, blogs at Me and My Stethoscope, and can be reached on Facebook.

Image credit: Shutterstock.com

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