Reaching the End of Life: What Do We & Loved Ones REALLY Need?

Recollecting, one of my patients was similarly diagnosed, suffering terminal lung cancer of the small cell carcinoma type, and had one lung removed. He had presented to the ED (Emergency Department) with extreme hypoxia (lack of oxygen), to such an extent that his lips had a distinctive blue cast to them. His oxygenation was so exceedingly poor, that he would turn in bed, and his sats (oxygen saturation level) would drop to 70% – neither a good, nor one that would sustain life.

In conversation with him, I asked him what he wanted to have happen to him, how he wanted things to turn out for him. He wasn’t under any misguided notion about his state of well-being or health and wanted to depart the ICU.

He said, “I want to go home to die.”

I responded by saying, “We want you to go home too. Let’s see what we can do to get you back there.” At that point, I began some very simple teaching about his breathing. He was a habitual mouth breather, and he knew it. I’d glance up at him, and his mouth would be gaping open as he watched teevee. Problem was, that every time his mouth opened, his sats dropped, even though he was receiving high flow O2 therapy via specialized nasal cannula.

So I instructed him that by keeping his mouth closed and breathing through his nose, his sats would increase. And barring any other unforeseen circumstance, were his sats to consistently maintain above 90%, that would be the greatest step toward his objective to go home.

At the end of my shift, he was consistently satting 98%.

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Doctors are practicing irrational medicine at the end of life

by Monica Williams-Murphy, MD on September 22nd, 2012, in Physician

I just took care of a precious little lady, Ms. King (not her real name), who reminded me that, too often, we doctors are practicing irrational medicine at the end of life. We are like cows walking mindlessly in the same paths; only because we have always done things the same way, never questioning ourselves. What I mean is that we are often too focused on using our routine pills and procedures used to address abnormal lab values or abnormal organ function, to rightly perceive what might be best for the whole person, or even what may no longer be needed. Our typical practice habits may in fact become inappropriate medical practiceat life’s end.Ms. King was a case in point: She was a 92-year-old nursing homepatient on hospice for metastatic breast cancer. Ms King had been transferred to the ER for a sudden drop in blood sugar, presumably due to her oral diabetes medication. Her appetite had apparently been trailing off, as is common at the end of life, and her medication appeared to have become “too strong.” Her glucose level had been corrected by EMS during her trip from the nursing home to the Hospital, so when I came into see Ms King she was at her ‘baseline.’I opened the door to bed 24 and a grinning little white-haired lady peered at me from over her sheet. “Hi,” she said greeting me first.“Hi, Ms King,” I smiled back at her and picked up her hand.

She reached over with her free hand to pat me on my forearm, “You sure are a cute little doctor,” she said smiling.

I couldn’t hold back a little laughter. “Well, you sure are a cute patient too,” I smiled and winked at her.

She winked back at me.

“Wow, this is the most pleasant 90-year-old I have cared for in a while,” I thought to myself.

As we chatted it became clear to me that she had some mild dementia but had no pain or complaints at the time. She just said, “I think I had a ‘spell’” ( a “Southernism” for some type of unusual and undefined episode of feeling ill or fainting); and “I’m not hungry” when I offered her food.

Leaving her room still smiling after our pleasant exchange, I went back to look at her medical record from the nursing home and two things immediately struck me:

Is there a Doctor (of Nursing) in the house?

I recollect one day, several years ago, at a then-small, rural community/junior college where I began my higher education, while walking across a parking lot, that I greeted an administrator whom I saw.

“Hello, Dr. Gudger!,” I cheerily greeted him.

“Good morning!,” came his reply.

Just then, another student, unknown to me or Dr. Gudger, called out, “Doctor! Oh, doctor! I have a question about my mama’s ...”

“I’m sorry I can’t help you. I’m not that kind of doctor,” replied Dr. Gudger, as he turned and looked the student in the eye.

At the time, I thought it rather odd, then quickly considered that the fellow – likely from a very rural and poor background – was there to obtain an education. And so in part, he was schooled that day.

However, interesting stories aside, as healthcare goes, our nation is experiencing a significantly decreasing interest in rural healthcare practice, as well as family practice, followed by internal medicine.

Now, I realize that some would pooh-pooh lawyers and blame law suits (everybody hates lawyers… until they need one), claiming that sue-happy folk are to blame for the problems. However, while law suits may have a role – albeit an insignificant one – insurance companies are probably more to blame for increased costs of healthcare and rationing the delivery of health related services.

It’s really rather easy to understand: Anytime anyone gets in between you and the checkout stand, you’re gonna’ pay more. From a fiscal perspective, that’s essentially what happens.

Now, while I could drone on and on about the hows and whys that the insurance industry is (in my opinion) corrupt (the federal government has also bailed them out, along with banks – which, along with stock brokerage houses enjoy an incestuous fiscal orgy), and has corrupted whatever thing their hand touches, I shall confine my remarks toward the more germane and problematic topic at hand, which is the shortage of healthcare delivery to rural areas, and among the poor.