Thursday, October 2, 2014

Access to Morphine - a Human Right

In a recent op-ed piece in the New York Times, it's noted that access to morphine is quite limited in the poorer countries:  "As with all successful human rights movements, we need to put a face on the injustice of untreated cancer pain. Witnessing a clinic full of poor children with advanced cancer, crying in agony, should convince anyone that access to morphine is a human right."

Palliative Care as a specialty is a relatively recent innovation in the USA.  More attention is now being paid to end-of-life situations, the access to palliative care even in the USA varies widely.  Morphine costs just pennies, but the concerns over narcotic abuse has limited its use worldwide.  I remember doctors and nurses not wanting to give too much over fear of addiction.  I'd say, "Look, the patient is dying and suffering.  Do you really think addiction to morphine is a concern?"

Careful titration of morphine at the end of life is a blessing.  It reduces pain and shortness of breath plus it produces calm and even euphoria thereby improving the quality of life in life's final days.  It's time to heed the call.  Let's continue to promote the appropriate use of morphine world wide.  It's inexpensive and doable.  It's not only the right thing to do, it's a human right.

Saturday, September 27, 2014

Institute of Medicine's Report on Dying in America

 Recently the Institute of Medicine has issued a comprehensive report on end of life care in America.  This two year review by a diverse and highly qualified committee was supported in part by an anonymous donor.  The complete report and summaries are available to download in a PDF format.

See this for a video report by the pannel.

A recent editorial in the New York Times discusses just how broken and difficult to navigate our "system" of health care can become.  Do we have the ability to improve?  Yes, but not without a lot of changes which are recommended in the Institute of Medicine's report.

Tuesday, September 2, 2014

End of Life Conversations - Progress?

Much is being made of the AMA's recommendation to reimburse doctors for the time they take in having end-of-life discussions with their patients.  The recommendations appear to have a good chance of being covered by Medicare and certainly are a step in the right direction.  But will one conversation and the completed documents really work?  Well, like so many other situations - it depends!

How skilled is the medical provider in having the conversation?  What kind materials are shared?  Videos?  Pamphlets?  Web sites?  What's the follow up?  Are the loved ones involved?  And, most importantly, does completion of the documents really affect end of life care.  We only die once so we get no practice at this or being a critically ill patient.  So how will we really understand the choices and make sure they are known?

There is some data that advance directives don't work, at times aren't honored, well prepared, or even available when needed.

Respecting Choices has attacked the problem successfully and systematically and should be a guiding force showing us how to do advance care planning in an effective programmatic fashion.  On the home front, I've been involved in presenting programs in the community called "Your Life Your Choices".  This program lasts 90 minutes and is well received but only scratches the surface of the complex choices.

A single reimbursable visit for an end-of-life discussion is a good place to start - but much more is needed in order to have an organized way to provide the care that the patient understands and truly wants.  There are technology drivers in medicine that can put a lot of us the ICU on life support.  The conversation and the directives can help, but often aren't definitive.

The POLST form is the most definitive document, but isn't available in many states.  It basically puts your wishes into medical orders which are legal and binding.

So it is beneficial to pay doctors to have this 15 minute discussion and have documentation of the patient's wishes carried out.  But we need to avoid a hasty and mechanistic way of doing this.  The conversation is never easy, straightforward, or simple.  Lots of clarification and questions need to be addressed.  The systems like Respecting Choices (above) address this well.

Thursday, August 28, 2014

Forever Young - Pete Seeger at 91

As I grow older, I find it so refreshing to be around my grandchildren.  It's their idealism mixed with innocence and craziness that attracts me and carries me back many years.  Also, I find it exciting and pleasing when my contemporaries "act young" - being willing to overlook their health complaints, to try new adventures, to volunteer, to connect with others, to sing and to dance.

All this reminds me of  Bob Dylan's song, "Forever Young".  Also when Steve Jobs died, Norah Jones played this song in tribute.

But my all time favorite version of "Forever Young" is the 91 year old Pete Seeger voicing this song with the Rivertown Children's Choir from Beacon, NY - Pete's home town along the Hudson River.  Pete couldn't really sing at that age, so a voice-over with the children's choir was professionally produced with amazing video and sound mixing.

He died peacefully on January 27, 2014, at the age of 94.  He was chopping wood until 10 days before his death.  According to Wikipedia, "When asked about his religious or spiritual views, Seeger replied: 'I feel most spiritual when I’m out in the woods. I feel part of nature.  Or looking up at the stars. [I used to say] I was an atheist. Now I say, it’s all according to your definition of God. According to my definition of God, I’m not an atheist. Because I think God is everything. Whenever I open my eyes I’m looking at God. Whenever I’m listening to something I’m listening to God.'"

May Pete's charm, enthusiasm, and music keep us all forever young.

Tuesday, August 26, 2014


Missing the dark side. 

How many times have I stood next to someone who gave up few signs and shared little, and camouflaged or diverted or joked so expertly that I thought he might be just like me - someone with connections and support?  "See you next week."  To take in a broader view beyond suicide, my heart goes to dying alone.  Dying in solitary, in no one's company, is a thought I can't abide.  I once worked in EMS in New York City.  Occasionally a call came to meet the medical examiner at an apartment, where someone would be pronounced, alone. If there were a pet who now was orphaned, it focused the nature of the loss and for me, amplified an unremitting pain for those who have no one.   Since then I have had to face my own death twice; as a nurse I have almost twenty years working in home hospice - yet nothing I experienced there can compare to the weight of these lonely deaths, which have given me some of the worst nights I have spent, before or since.

Robin Williams:  "I used to think the worst thing in life is to end up all alone.   It's not. The worst thing in life is ending up with people who make you feel all alone."  
I would dread facing that choice.       

Terry Hourigan, R.N.
Photo: Frank Burnside

Sunday, August 3, 2014

Medical Ethics - Paternalism vs Autonomy

I was taught in medical school (some 50 years ago) that doctors had a special duty to protect the patient.  That seemed self evident and logical.  "Do no harm" was a first principle dating back to Hippocrates. However the teaching I received extended the concept to also protect the patient from bad news, and to make "the right" decision for them - not necessarily including them in the conversation or decision making because "it would be too hard on them.".

"Students, you should never tell a patient of the diagnosis of cancer", pontificated our chief of surgery.  "You should protect them and not give them a fatal diagnosis.  Do not tell them that the cancer has progressed, but do let a trusted family member know."

Thursday, June 12, 2014

When to Consider Boerhaave's Syndrome

Mary, at age 77, fell and was admitted to the hospital with a hip fracture and had surgery the following day.  Post-operatively she received narcotics for moderate pain.  Unfortunately she had vomiting and retching, then developed severe abdominal pain.  She had a history of a prior appendectomy, prior gall bladder removal, moderate COPD, and mild heart failure.

Accompanying the pain, her blood pressure fell, she became short of breath, and her oxygen levels fell.  This rapidly progressed.  Cultures were taken for infection, a chest X-Ray done, and antibiotics initiated.  Her kidneys began to malfunction and early signs of shock were present.

Her doctors thought of aspiration pneumonia, esophagitis, a dissecting aneurysm, heart attack, pneumonia, and pulmonary embolism - but were on the wrong track.  The X-Ray should have helped but was interpreted as not showing free air around the lungs or in the soft tissues.  A subsequent CT scan however, did show an abnormal collection of air in these areas.

Finally after 18 hours of going down the wrong path, a diagnosis of a ruptured esophagus was considered.  This was confirmed by putting some contrast dye down the esophagus showing it to leak into the surrounding tissues.  Also, an enzyme only present in saliva was present in the fluid from around the lung.

She was taken to surgery for repair 24 hours after presenting with pain, at a time when the mortality begins to approach 50 - 75%.  Unfortunately she continued to deteriorate and ultimately was placed on comfort care prior to dying.

Comment:  Herman Boerhaave was a brilliant Dutch physician, botanist, and humanist who, in 1724, described a corpulent patient's proclivity toward self-inducted vomiting in allow him to indulge in further overeating.  At autopsy his patient, Baron Jan Van Wassenaer, had olive oil and roast duck flesh outside an esophageal tear.  The condition known as Boerhaave's Syndrome is relatively rare but one of those bits of knowledge that needs to be in the thinking of surgeons and critical care physicians.  Unfortunately a delay in diagnosis of 24 hours leads to a very high mortality.  Samuel Johnson has written an interesting biography of Boerhaave.

Sunday, May 25, 2014

CPR Without Consent

Agnes was out shopping at her local corner store.  At age 82 her body was beginning to show typical signs of aging.  She had survived breast cancer surgery, a hip replacement, and cataract surgery.  Her doctors told her she had osteoporosis and low Vitamin D.  She took medications for her hypertension, cholesterol, and osteoporosis.  Her spine had begun to curve and her gait was a few steps slower.  Yet, with her shopping cart she still enjoyed her trips to the store.  Her best friend had suffered a cardiac arrest recently and didn't survive the hospital stay.  She discussed this with her retirement home personnel and decided she never would want CPR.  A "Do-Not-Resuscitate" order was initiated by completing a POLST form (Physician's Order for Life Sustaining Treatment).  She made copies of the POLST form giving them to her physician and retirement home staff.

While at the corner store, Agnes felt light headed and sat for a moment but then slumped to the floor.  Shoppers at the store immediately started CPR and 911 summoned the Medics.  With the standard 1.5 to 2" compressions of the sternum, multiple ribs were broken and the lungs were later found to be punctured.  Her heart rhythm was "shockable" and after 5 shocks, she stabilized and was taken to a nearby ICU.  The next few days were stormy both medically and ethically.  The hospital staff felt they had preserved a life, yet the family said she was ready to "pass on" and didn't want the heroic life support.  Finally the family and POLST form wishes prevailed and she was "allowed" to die in the ICU after the tubes were removed.

Comment:  Society generally prohibits us from medically or surgically treating a patient without their informed consent.  However society places, quite naturally, a high value on preserving life.  Since the 1960's CPR has been evolving and improving.  It has been popularized on multiple TV shows such as ER, where the survival rates approach 66%, much higher that the real word data (which continues to improve).

The "frail elderly" are a particular problem because the trauma of CPR may cause more harm than good in some individuals.  The statistics of young people don't apply to the elderly.  And many elderly just don't want CPR saying, "I've had a full life and having my heart stop wouldn't be a bad way to go."

Yet all of us are "signed up" for CPR, unless there's a really clear way to avoid it.  Some families simply don't call 911, some have POLST forms, or some spouses and caregivers are able intercept the process by demonstrating they have power of attorney for health care.

The American Bar Association has come up with a smart phone app to store advance directives and other medical data which might be helpful to the techie generation.  Some states have free registries and there is a fee based national registry for advance care documents, but finding these can be difficult in the acute situation.

The frustrating bottom line for the "frail elderly" is that very few of us have had an informed consent discussion about the pros and cons of CPR.  And even if we decide, "Heck, I'd never want anything like that", a lot can still go wrong in terms of knowing and respecting our wishes.  Even a "No Code" tattoo on your chest isn't legally binding!  So in addition to having "the conversation" with your doctor and loved ones, try to come up with a plan if you really want to avoid CPR.  One thought is to electronically store any POLST/DNR orders with 911 responders.  That way, when they are summoned, the orders will be immediately available.   This may a concept worth field testing.

Friday, April 25, 2014

A Moral Community in the ICU

When I entered the room, my patient was surrounded by worried family.  They had lots of questions.  My concern was that I didn't know either the patient or family.  Dan had been brought to the ICU after a cardiac arrest outside the hospital.  The medics had gotten the heart restarted with CPR and shocks, but Dan was unconscious and on a ventilator.  So how to begin?

I introduced myself and explained that I needed to examine Sam and get more information from the family, then we would see what else we needed to do.  The anxiety was palpable.  He was soon to also be seen by the neurologist.  The cardiologist felt that his heart was "stable" and that he had had an arrhythmia, not a heart attack.

A son from Minneapolis was calling in.  The two other children at the bedside and Sam's wife, Marilynne, were in tears.

So how do I proceed from here?  The medical evaluations were pretty straight forward.  But communicating with the family is something I only learned over time.

Family conferences and  decision making with the medical providers occurs daily in the ICU, but the effectiveness varies widely.  A medical social worker and I developed a shared decision making pathway for medical providers to use.  One of the steps in the process is the concept of forming a moral community.

We would invite the family to meet in a quiet place, have a telephone/speaker for those unable to be there, and go around the room introducing ourselves.  The moral community concept is much like what goes on in an ethics committee discussion. The discussion centers around the patient's wishes and values respecting the patient's autonomy.  The community of caregivers (medical and family) begins to form around those values and wishes.  Caring, empathy and sharing are all key to begin to have the group act functionally as a moral community.  Modeling of these behaviors at times helps deal with the anger and frustration often present.

For more information please see our publication about a guide to shared decision making in serious illness.

Dan's family was devastated that he suffered irreversible brain death following his cardiac arrest.  Using shared decision making they agreed with removal of life support.  Allowing transparency, showing caring, focusing on Dan's wishes and values - all of these gave the family a sense that they were doing the right thing.

Tuesday, April 8, 2014

Is the Use of the POLST Form Controversial?

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 ICU saying, "We got a sad situation here.  He explained what happened and that the daughter, who finally found Mom in the ER, was distraught saying, "None of this should have happened."

We let the patient die in the ER, had social service work with the family.  The medics were upset that they'd performed CPR ("medical last rites") in such a patient.  The ER wasn't pleased to have a patient die there but a hospital admission seemed pointless.

The POLST (Physician's Orders for Life Sustaining Treatment) was pioneered in Oregon in 1991 and has gradually worked its way state by state so that about 26 states now have a POLST statute.  It has been validated in Oregon to be effective in honoring a patient's wishes.  The medics I have worked with have praised the POLST form because it tells them exactly what to do, or not do, if they are called and the form is available.

The POLST is most commonly advocated for those expected to die within a year or the very frail elderly.  The form translates the patient's values and wishes into actual medical orders which will be honored by 911 responders.  In Washington the form must be signed by the patient (or surrogate) and the medical provider.

But it's not without controversy and the criticism sounds much like the fear over Death Panels which has, gratefully, died away.  Conservative Catholic bishops in Wisconsin and a few media sites have warned of the dire consequences of POLST forms.  Their criticism implies that they are Do Not Resuscitate forms that also withhold antibiotics, fluids and nutrition.  Actually the forms do allow for a wide range of choices from full care, limited care, or comfort care.  They are intended to put the patient's wishes into real time medical orders.  They can be revoked by the patient or surrogate if circumstances change.

Probably the most common site for the use of the POLST is with Hospice patients, who are expected to die within six months.  But there is a tendency now to use (or even try to require) the use of the POLST form in retirement community facilities and nursing homes.  Recently I gave a talk about advance care planning to a well known retirement community in Seattle.  "How many of you have completed your Living Will and Power of Attorney for Health Care?", I asked.  80 or 80 responded positively.  But the surprise was that 70 of 80 had completed POLST forms.  These were folks probably from their mid seventies up into the 90's but all were in independent living (no assisted living, etc.).  To me this is a surprising use of the POLST form and goes beyond its initial intention.  Do all of the 75 year olds really know their wishes about a ventilator for pneumonia, or CPR, etc?  Of course the POLST form can say, "Do Everything" but then it becomes redundant.  Also, in a practical sense how is the POLST form going to be reviewed or retrieved if the patient is in the dining room or gym or out shopping?  Registries can be tried but real-time access is needed in the acute situation for the POLST to prevent unwanted CPR (hence bright color is used so the medics can spot it).  However, some aging rather healthy folks seem sure that they do not want CPR in any circumstances.

At a talk I gave yesterday in California, a couple showed me the bracelets they were wearing that referred to their completed POLST form.  He was in his 80's and she was a hospice chaplain in her early 70's.  I asked her, "How can you really be sure that you'd not ever want CPR?"  She responded, "I just don't like the odds.  I'd rather pass on tha than risk severe brain damage.  I've had a pleasant life, and a cardiac arrest wouldn't be a bad way to die, ever though their might be a 25% chance of getting me back to my normal self with CPR."  So this use of POLST may have this practical use in certain well informed folks who are sure of their choices, but it seems ill adapted for this.  Will the 911 responders really see their medic alert bracelets and will they really have time to find, thus honor, the POLST?

Even with this latter concern of mine, the benefit of the POLST is huge. Recently, the American Medical Directors Association indorsed the POLST,  But becoming mainstream in our rather broken heath care "system" in the USA will require more time for the POLST.  We can only hope that the remaining states can learn from the pioneering efforts in Oregon.  It indeed honors patient autonomy and choice.  And the states where the POLST is currently used, should have oversight and guidelines for appropriate use.

Wednesday, March 5, 2014

Vitamins Don't Work - Enough is Enough

When I was in medical school, our nutrition researchers taught us that vitamins didn't do much good and only made expensive urine (where the water soluble ones end up).  We did learn about the classic vitamin deficiencies like scurvy, beriberi, rickets, etc.  But the evidence that healthy people should take vitamins was marginal at best.

Is our search for immortality the reason that we turn to the pill or potion?  Do we continue to look for the fountain of youth that is linked to the Spanish explorer Juan Ponce de Leon.  (Though de Leon was really looking for the isle of Bimini rather than Florida and there's no mention historically that he was searching for perpetual youth.)  Yet the myth and tourist site remain popular.

So why do we turn to vitamins, supplements, anti-oxidants, nutriments, etc?  William Osler commented that “the desire to take medicine is perhaps the greatest feature which distinguishes man from animals.” Also Osler taught his medical students, "One of the first duties of the physician is to educate the masses not to take medicine."

Osler's concerns have been valid over the years, but often have been drowned out by errant science and the hype of the vitamin and supplement industry.

There have been prominent scientists who have been strong proponents of vitamins and supplements. Linus Pauling discovered the structure of ascorbic acid (vitamin C) and won the Nobel Prize in Chemistry.  Unfortunately he became a "true believer" in vitamin C and other vitamins: "Pauling is largely responsible for the widespread misbelief that high doses of vitamin C are effective against colds and other illnesses. In 1968, he postulated that people's needs for vitamins and other nutrients vary markedly and that to maintain good health, many people need amounts of nutrients much greater than the Recommended Dietary Allowances (RDAs). And he speculated that megadoses of certain vitamins and minerals might well be the treatment of choice for some forms of mental illness. He termed this approach "orthomolecular," meaning "right molecule." After that, he steadily expanded the list of illnesses he believed could be influenced by "orthomolecular" therapy and the number of nutrients suitable for such use. No responsible medical or nutrition scientists share these views."

Finally in modern times we now have a better view and summary of the ineffectiveness and harms of vitamins and mineral supplements published in the December 13th Annals of Internal Medicine:  "Vitamin and Mineral Supplements in the Primary Prevention of Cardiovascular Disease and Cancer: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force"

The bottom line is that vitamin and mineral supplements for healthy individuals don't work and some may be harmful.  The editorial in the same issue concludes:  "β-carotene, vitamin E, and possibly high doses of vitamin A supplements are harmful. Other antioxidants, folic acid and B vitamins, and multivitamin and mineral supplements are ineffective for preventing mortality or morbidity due to major chronic diseases. Although available evidence does not rule out small benefits or harms or large benefits or harms in a small subgroup of the population, we believe that the case is closed— supplementing the diet of well-nourished adults with (most) mineral or vitamin supplements has no clear benefit and might even be harmful. These vitamins should not be used for chronic disease prevention. Enough is enough."

Recently Dr. Oz had a disastrous take-down in a Senate hearing about his "magical" claims of dietary supplements.  This is reported with bitingly epic humor is this epic video.

Monday, February 17, 2014

The Medical Industrial Complex is Driving Costs and Overtreatment

"Hey doc, I saw on an ad on the TV last night about this new asthma inhaler.  Shouldn't I give it a try?"  This type of question would occur several times a week.  When I started practicing medicine it was considered unethical to advertise medical treatments.  Now, we're bombarded with enticements for tests and treatments.  The inhaler the patient requested cost $264 a month - more than double what he was currently paying for an effective generic inhaler.

Somehow, we have brought into the hype that more is better, and that if you would just get your mammogram or PSA, that early detection would prevent cancer deaths down the line.  A recent study in the British Medical Journal found that the death rate comparing mammography with annual breast exams was no different.  And a significant number mammography patients went though additional surgery, radiation therapy, or chemotherapy - which was unnecessary.  The effectiveness of PSA monitoring remains controversial, and many prostates are being removed where the negative effects far outweigh a theoretical possible benefit.

The evening news ads bombard us with "low T" warnings and erectile dysfunction treatment promotions.  Somehow, testosterone experimentation is happening, much like the era of  hormonal replacement for all menopausal women.  The warnings of these drugs like blindness, rising PSA, or stroke are gently spoken while watching loving couples swimming or smooching.

A friend is now monitoring her glucose daily, even though she is barely pre-diabetic.  Somehow, she feels the need to be constantly monitored for the condition she does not (yet) have.

A 90 years old wants his cholesterol checked.  He'd like a drug for it that he saw on TV.  Really?

Most of now have a medically attended birth and medically attended death.  We now have the benefit of effective medications for blood pressure, diabetes, and abnormal lipid panels.  But the medical industrial complex wants us to be major consumers - more visits, more tests, more surgeries.  There is some evidence that may be making the industry nervous as health cost increases seem to have leveled a bit.

The industry to struggling a bit to bring out new blockbuster billion dollar drugs.  The dollars that go into the health care system are coming from our pockets and insurance premiums.  Given the waste and inefficiencies in health care delivery, this hurts the entire economy and has allowed the medical-industrial complex to become bloated.  Obviously a balance is needed.

There is bloat in duplication and overuse of high tech equipment.  The fastest way to pay off a new scanner is to run more tests.  The incentives are to do more in the fee for service system.  Pharmacy and device sales reps abound in doctors offices and hospitals.  Ethical lines are blurred when free meals and paid lectures are offered to MD's by the industry.  TV and magazine ads drive up cost and utilization.  Administrators want a lucrative bottom line.

Interestingly, we seem to be at a break point in terms of medical costs.  More is being shifted to patients as companies offer only HSA plans and often high deductibles.  More doctors are becoming salaried.  Malpractice settlements have peaked and appear to be declining with subsequent savings in malpractice premiums.  More efficiencies appear to be evolving.  The congressional budget office has reduced its estimates of Medicare spending by 12% (109 billion) by 2020.

My concern is the that medical industrial complex will become even more aggressive.  The possibilities will be more ads, direct mailings, "free" screenings, discounted surgeries, false claims of testing and treatments, etc.

My advice:  be a careful and cautious consumer.  Don't become medicalized.  And to the medical profession:  be more proactive countering the barrage of biased information we hear and see daily.

Thursday, January 30, 2014

Cancer? How Much Time Will You Give Me?

Ben's first symptom was coughing up blood.  The cancer had been silently growing for months, if not a few years.  He had no pain or shortness of breath.  The chest X-Ray showed a "5 cm L hilar mass" and the subsequent CT scan showed enlarged lymph nodes and likely spread to the liver.

"So Doc, what is it?  A cancer?  How much time do you give me?"  All these questions on a first visit when I don't really know Ben, his family, or life situation.  As a pulmonologist, this scenario happened once or twice a week.  The patient was usually a smoker but Ben was not.  At age 49, he'd been a basically healthy guy.

I always found it important to say, "I don't know, but let's find out what's going on and here's the plan I'd suggest".  This usually included blood tests, the CT scan, and a bronchoscopy to find the diagnosis and make further plans.  It was far too soon to jump to Ben's future, but Ben said "Come on Doc, give me your educated guess."  I'd usually say, "My crystal ball is cloudy and I can't read your future but I promise I'll tell you all I know as we go along".

Bronchoscopy (from a pulmonologist's point of view) is a pretty simple outpatient procedure.  With the use of lidocaine to the vocal cords and airway and with very light use of short acting sedatives or narcotics a thin flexible scope is passed through the nose (usually) into the airways and everything is seen on a video monitor.  Ben's tumor was evident in the L mainstem bronchus - red rough angry looking tissue.  Biopsies of the tumor were done - and Ben wanted to see the monitor.  I showed him the findings and explained that we would know the diagnosis the next day.

It was a non-small cell carcinoma of the lung - the most common type.  Again Ben asked, "OK now how long to I have."  Small lung cancers that are near the periphery of the lungs have the best outlook and are often curable.  However Ben's cancer was subsequently proven to Stage 3B.

Again, Ben's question and how should I answer it.  Recently in the New York Times a young Neurosurgical Resident posed the question, "How Long Have I Got Left".  Where is any patient on the statistical curve?  How can we begin to know what the response to treatment will be?  Actually in the last decade there have been some significant improvements in treatments and survival in some patients, but the measured improvements are sometimes in months rather than years.

I would say to Ben, "I don't have the powers of a deity and can't see the future, but these are the broad statistics.  I'm hoping you may not only beat the averages but be an outlier.  You are younger and healthier than many of the patients studied.  You're not a statistic.  I'm sending you to the best cancer treatment and research center available so let's see what they have to say.  But it's going to be one day at a time.  I'd like to see you again once a plan is set in place.

Comment:  "Giving a patient time" can be self-fulfilling so doctors must be careful.  On the other hand, refusing to lay out the realistic outcome of other patients (statistics), is denying the patient of information they often want to know.  Staying connected with the patient provides emotional support as they transition to oncologists or surgeons.  It's the human to human connection that makes medicine the most powerful - and humane.  It's also important not to dodge the issue of death.  When the patient reaches the stage of dying, doctor's often fail to tell the patient that it's time for hospice and comfort care.  We need to be comfortable with mortality and frailty - both our own and the patient's.  We need the judgment and wisdom to guide the dying patient to palliative and comfort care.

Friday, November 29, 2013

What's a Type A Continuing Care Retirement Community?

John and Eva had ongoing conversations about their home which was now far too big for their needs and lots of trouble and expense to repair and keep up.  John said, "It's the yard, the leaves, the painting, and general repair and replacement problems.  What's next to go?  The refrigerator or me?"  Eva was tired of shopping and cooking.  Her arthritis was slowing her down.  She told John, "OK, you retired from work, but when do I retire from cooking?"  Also, they were beginning to lose contemporaries and their social life was shrinking.  There was a growing sense of isolation.  Their children and grandchildren had busy lives and couldn't be part of their daily life.

The started looking around at Continuing Care Retirement Communities and found lots of options and a fair amount of confusion about what might be future costs.  They were leaning toward a "Type A" CCRC, but each of those had somewhat different costs, though they were much more inclusive than Type B or C, the latter being fee for service.

But the headaches were just starting.  They had raised four children who were now on their own, but the remnants of their possessions were still in their house along with "stuff" that they had inherited from prior generations.  John read an article about "possession paralysis" in the New York Times and shared it with Eva.  "It fits us doesn't it Eva.  We're both pack-rats and we have been putting off moving partially due to all the "stuff" we have."

So they began to downsize - trips to the library to donate books, trips to Goodwill to donate, giving things away to family, but this hardly made a dent.  "We have all this china, crystal, and silver but there's just no market except for the silver metal.  Don't kids entertain any more?"  The children began to step in with Craig's List, eBay, and hauling stuff out to their own homes and an estate sale.

They finally found the CCRC they were hoping for and it came time to do a pricey buy-in which was painful even though their estate would get 80% of it back.  The housing market was beginning to bounce back and it seemed like a good time to put their home on the market, get a "bridge loan" and plan a move.

Both John and Eva found the whole experience stressful, but couldn't see anyway around it except to continue on in their own home, and hire in help eventually if needed.  Eva said she was so emotionally attached to family things that "possession paralysis" felt very real to her.  Yet she didn't want to handle all the house issues if something happened to John.

It took about 6 months for the house to sell, the CCRC move to occur, and almost that long to dispossess themselves of all their "stuff".  Selections were finally made, charity trucks carted off many boxes, and the "kids" came with U-Haul trucks.

Eva remained in good heath, but within a year of moving into the CCRC, John developed rapid onset Alzheimer's.  He was moved to the Memory Care Unit, while Eva could stay in her independent apartment in the same complex.  She was able to participate in John's care without being overburdened by worry about safety or costs.  His long term care was fully covered and their were no additional expenses.

Comment:  We are on the cusp of having the Boomer Generation entering into the final phases of their lives.  The problems and expense will be huge.  Very few folks have long term care insurance and some still assume that Medicare covers long term care - it doesn't.  We aren't well prepared as a society to deal with these problems.

Monday, November 25, 2013

Why Is Hospice Often Delayed?

Les called me about his PSA.  "Jim, it's rising and now up to eleven and they're recommending treatment.  What would you do?"  Even as a long retired MD, I still get medical calls from friends and relatives.  Actually, I feel honored and try to do my best, researching the latest journal articles and editorial opinions.  Of course, the prostate cancer literature is cloudy at best with scant evidence that the huge number of surgeries are actually saving lives.  Most of us die with prostate cancer but not of prostate cancer.

Les went ahead with surgery which proved to be both difficult and non-curative.  The cancer was found to have spread into the pelvic lymph nodes, plus he went into a very rapid irregular heart rhythm requiring a stay in the ICU for a few days.  After that he was given radiation and hormone blocking drugs to try to stop the cancer.

Les seemed to stabilize and did reasonably well over the next four years, but then developed pain and fever in the left flank.  The CT scan showed that the kidney was obstructed by a tumor mass.  Looking in there with a scope, a small stent was passed up into the kidney to drain the pus, and a new cancer found in the area - most likely secondary to the radiation he received.

As Les become weaker the family rallied around.  Jeannie, his wife, and the three adult children and seven grandchildren were supportive.  Jeannie went with Les to the Oncologist who prescribed chemotherapy to "buy time", but again there were complications.  Les became weaker, lost all sense of taste and smell, and it was found he had a very low serum sodium level.  This required hospitalization, water restriction, and very expensive drugs.

About this time, Les said "NO MORE".  The treatments had devastating effects that weren't benefiting him.  Jeannie was providing all his care at home, a hospital bed and recliner were purchased, and part time help employed.  The doctors were "giving" Les about a year to live, but when I stopped by to see him, his skin was pale and clammy, his pulse 120, and he could barely stand up.  I asked Jeannie what she would do when the end came.  She said, "Well, I'm not going to call 911 because they would come in and do CPR and Les certainly doesn't want that."

As gently as I could, I recommended that Jeannie talk to her doctors about hospice and introduced her to the POLST form.  Her first reaction was that Les wasn't sick enough yet for the "6 month prognosis".

I responded, "Jeannie, why not just ask for a hospice evaluation and let them get to know him and evaluate his current status.  They are really great at this.  I gave her a Hospice brochure and a POLST form and suggested that she and Les discuss this with their doctors."

Fortunately Les was shortly thereafter on hospice with a signed "DNR" on his POLST form which would be honored by Medic I if called.  Extra help was provided and Jeannie began to get a little more sleep.  Les died a few weeks later with Jeannie and family at the bedside and the hospice nurse present.

Comment:  The stays in hospice remain far too short despite their amazing benefit to patients and families.  One surgeon said, "Dying without hospice would be like having surgery without anesthesia."  One cause of delay in hospice referral is the Medicare requirement that all curative attempts be stopped on entry into hospice.  Medicare has been delayed in initiating a trial to allow continuation of curative attempts while in Hospice.  It remains understandably hard to make the mental and emotional switch from the curative mode to the comfort measures only mode.  So we all need to work on this - the physicians, support groups, chaplains, families, and those involved with palliative care.  Many are unaware that their insurance plan may offer hospice benefits under the age of 65, and also pre-hospice benefits may be available for those wishing to continue curative efforts.

One of the newest specialties in medicine is Palliative Care - those who take a holistic view of the patient, focus on symptoms and comfort measures while taking into account all the variables like spiritual beliefs, other specialties involved, family dynamics, etc,  Long considered to have opposing views, Intensive Care and Palliative Care are finally coming together in the treatment of patients.

Spending my career presiding over many deaths in the ICU, I would have to be prepared to lose a patient after spending days and weeks trying to save the patient.  This requires a shift in thinking and intent - sometimes a huge adjustment for all involved.  Physicians and other care-givers need training and support to acquire palliative skills and this is being done (finally) at a number of institutions such as the University of Washington.  You can log on and become a member if you wish.

Monday, November 11, 2013

Helping A Patient Die - Death with Dignity

Recently at a conference, I invited others to consider posting their stories on this blog about end of life issues.  The following story is from a physician who volunteers with Compassion and Choices in Washington State.  About 1 in 500 deaths in Washington state (0.2%) occur by utilizing Washington's Death with Dignity law - passed by a 59% margin several years ago.  Oregon's similar law was also passed by a voter initiative, and Vermont's legislature recently passed a similar law.  Here is this physician's story:

"As a Client Services Volunteer for Compassion and Choices of WA, (C&C) it is my privilege to help a dying person in choosing his/her way of dying.

A few years ago I helped an incredible woman, 64, end her life.  She had gotten the diagnosis of lung cancer, unrelated to smoking, 4 years earlier.  In the midst of an active and successful career as a consultant for large companies seeking more effective Human Resources, she was stunned by this news.  She had some surgery, which relieved her difficulty with breathlessness, followed by chemotherapy.  The bouts of chemo were hard to tolerate for her as an always healthy, exercising, normal weight person.  But she got through them and enjoyed a remission of 2 years. 

A year later, recurrence was found in her lung, brain and liver.  Radiation and more chemo seemed to shrink these lesions, but her mental acuity was slowly decreasing.  She and her husband decided to pursue, via the Death with Dignity Law, an option to end life if she needed to do that.

Because she had obtained a prognosis or 6 months or less from her physician, she was eligible for that choice in WA. I was called when they contacted C&C, so I met with them in their condo.  We began the process specified by the Law. After another physician confirmed her diagnosis and prognosis, she also was found to be non-depressed and mentally competent to decide.  She completed the Written Request form and the waiting period.  Finally, she obtained the prescription from her personal physician.

She continued to work past her initial 6-month prognosis.  Then her strength forbid the traveling and exertion required.  They took the trip to Antarctica she had always wanted.  However, she again used her strength of character to get there.  Predicted bad weather caused the captain of their small ship to turn back toward the Cape of Good Hope, but she rallied the other passengers to demand that the captain check and recheck the weather.  A better forecast allowed them to proceed to Antarctica. 

She decided to set a time for death when she was unable to go outside for walks with her husband and she was getting more short-term memory loss, to the extent that she could not read books.  They got a rental hospital bed for the living room.  They invited close family and arranged a time with me.  On a weekend morning, after a light snowfall near Christmas the family spent time sharing memories and she took anti-nausea medications.  I arrived and mixed the powder with warm water.

She expressed her love for each person and her gratitude to me.  Holding her husband closely, she drank the small amount of liquid.  She chased the bitter taste with a favorite juice.  Her family gathered near her and held each other.  She quickly slept and died."  Posted by an MD.

Comment: Years ago I had a similar case where I was pretty sure that a patient with end stage mesothelioma was squirreling away sedatives and contemplating ending his life of suffering with an overdose.  He was suffocating as his lungs were being progressively compressed by tumor masses.  I presented his case to our Ethics Committee and was surprised that the Ethics Committee supported his autonomy even though it appeared to violate the "Do No Harm" ethical principle (and was against the law at that time).  In reality I think it could be argued than harm was being forced on this man by not giving him the help he wished.  At any rate I think he may have ended his own life with medications.  How often is this quietly done?  Probably much less often now that Hospice is widely available and a Medicare benefit.  JdeM

Thursday, August 8, 2013

Allowing a Patient to Die - Yes or No?

I was recently invited by KUOW's Katy Sewall to be interviewed about the use of ventilators in the ICU .

In the interview I note two patients.  Both begged to be taken off the ventilator and die.  In one we followed his wishes, in the other we didn't.  In another patient, the family begged to stop; yet in another a family begged to continue.  Death thus becomes a negotiated event in the modern ICU - a real tour de force in applying the ethical principles of autonomy, do-no-harm, and beneficence.

In the back of my mind during the interview was a recent lecture from Coursera (free on line) where they were tying to define death.  It used to be pretty simple - when the heart stops you die.  Well, with new interventions such as hypothermia, a higher percentage of patients are surviving than the current rather dismal 15%.  So they simply stated, that death really is defined by when we stop resuscitation!  I can see from an EMT or ER physician's training that this would be their focus, but the vast majority of us simply have the dwindles from old age sometimes complicated by cancer or heart disease or dementia.  For the frail elderly, CPR rarely works and many patients have standing orders to prevent the terminal assault of chest compressions and electric shocks.

But it's not always straightforward in the ICU in terms of the ventilator.  It's the system support of last resort, bringing oxygen into the lungs and getting rid of CO2.  When everything else is failing we need to talk about the ventilator.  Is it really helping or just prolonging dying?  About 70% of all deaths in the ICU are from withdrawing the ventilator.  Everything else has been tried.  It can be a bumpy road in shared decision making for families and physicians.  Letting go is often the right thing to do, but it's never easy

Thursday, August 1, 2013

Sorry Seems to be the Hardest Word

Elton John had it right, "It's sad, so sad.  Why can't we talk it over. Oh, it seems to me that sorry seems to be the hardest word."

Mistakes are all to common in medicine, but can we say the "hardest word" when we're involved?

Example 1: There's a diagnosis of recurrent lymphoma in the ICU. The oncologist gives a phone order for cytoxan, prednisone, and vincristine. The recorder, working a double shift, mistakenly writes the vincristine daily for 5 days similar to the prednisone order. The fatal dosage is given to the patient over the ensuing days. He dies in bone marrow failure.  The oncologist met with the family and apologized.  A review was carried out.  Systems were improved.  There was no lawsuit.

Example 2:In a radiology department, a cleaning solution rather than a dye is accidentally injected into a patient's femoral artery leading to a painful death.  The hospital representatives and physicians promptly met with the family, admitted a mistake, apologized, and a financial settlement was offered and eventually accepted.

Example 3: A pharmacist fills a prescription for a patient with asthma. Instead of prednisone, the pharmacist mistakenly counts out digoxin, a pill given for heart disease. Digoxin can have severe side effects even at a dosage of one a day. The prescription is followed by the patient: take 8 a day for 3 days, 6 a day for 3 days, etc. The patient calls the MD about the symptoms of severe nausea and notes the pills look different than usual. The medication is stopped and with treatment the patient luckily survives digoxin poisoning.  No apology was forthcoming and the patient lost confidence in the integrity of his providers.

Medical errors frequently hit the headlines. Magazine articles, such as "How the American Health Care System Killed My Father", can be both thought provoking, and provocatively accusatory. Stress and fatigue often play a role.

Medicine is a proud profession, with medical ethics at its core.  But it's complex and fragmented.  Atul Gawande promotes improvements in standards of practice but implementation is difficult.  Medicine is highly regulated in attempts to control quality. Currently doctors, nurses, pharmacists and others can face hospital sanctions, medical disciplinary boards, media scorn, and malpractice threats when they make mistakes. In most situations, a number of things have to go wrong at the same time in order for the mistake to occur. None of the above are my personal mistakes, but "I've been there, done that!"

On a personal level it's humiliating and devastating to be involved in a serious mistake. I sat down with a psychiatrist friend after a significant mistake and it helped to talk it out, but the hospital's legal department had to be notified, affected family members met with, and eventual reports to the state dealt with (and this is in the middle of a 60+ hour week). Fortunately I was not sued, but the worry was palpable.

There's pretty good data now, that fessing up is the best thing to do from a legal standpoint and certainly from the moral view. But believe me, it's not easy when you'd rather hide. When one patient died after a procedure that I probably shouldn't have attempted because he was so sick, I sat down with the family and explained the whole sequence. The son had lots of questions, but then looked reflective and said "It must be hard to be a doctor sometimes. Look it's OK. Dad was going nowhere and he's in a better place now." Basically, he had let me off the hook.

On the prevention side, there's good data from systems engineers (like Toyota and Boeing) that critical mistakes can often be prevented with good quality management and systems surveillance. All hospitals and major clinics have extensive quality control and review. The answers can be simple or complex. For example, for some recent eye surgery I had, I was asked my name and birth date three times by three separate people (even though they all knew me) - along with what operation I was having and on which side. These quality/safety techniques require constant review, updating, and reporting.

There are quality ratings of hospitals by procedures that can be reviewed. The hospital that does large numbers of, for example, carotid surgeries will almost always have better outcomes and fewer mistakes than the hospital that only does a few. It brings into question the future role of the smaller hospitals. The issue is not so much mistakes as the inability to match the experience and quality of an institution that does large number of a complex procedure.

How do we deal with all the parties involved in a mistake (the patient, family, providers, institution, legal, insurer, etc.)? The answer is both simple and difficult - apologize!   Mistakes can be honestly dealt with.  A good example of this are the tort reforms successfully instituted in the state of Michigan. In many states, a doctor's initial discussion with the patient and family about a mistake is not discoverable in a lawsuit.

It is best for all involved to personally make a face to face apology! Sometimes one is forgiven, then sometimes not. But if animosity can be decreased, often a settlement can be reached after an honest admission of a mistake.. Involving the patient and/or loved ones in a case review with all present can be very powerful. It's very hard to stay angry or want to punish someone who can look you in the eye and sincerely apologize, plus actively listening to all your concerns. There comes a point that we all recognize that we're "only human."

Wednesday, July 24, 2013

The "D" Word. Is the Conversation Finally Starting?

A friend wrote from Portland that he recently attended a Death Cafe!  He was enthusiastic about the breadth of the discussion about care giving, making choices, grief, spirituality - essentially a wide ranging conversation about death.    Additionally, from the University of Washington there's a program promoting conversations over the dinner table - dinner and death (really!).  Also you can now purchase a game to promote the conversation about end-of-life choices.  And finally, Scott Simon, NPR commentator, recently sent out bitter-sweet tweets about his mother's dying - a mixture of grief, humor and the mundane. Are we finally breaking down barriers about the "D" word?  Is this the beginning of a groundswell of interest.  Maybe, maybe not.

I listened last year to TR Reid who gave a lecture to Group Health Cooperative's Annual Meeting.  He highlighted the costs of health care around the world and the shortcomings we have in the United States.  After the talk, I approached him and asked if he would be interested in writing a book about how Americans approach death, the excess costs and procedures in the American style of dying, etc.
He said, "That's too difficult a subject.  My family gets all emotional when I even try to bring up my eventual death, so I can't go there."

So it seems like we still have many barriers to discussion:  denial and procrastination being right upfront.  Ellyn Goodman is promoting the front end conversations with loved ones.  That's a great starting point, but we really need much more education.  Approaching death without learning about CPR and tube feeding is like having surgery without having a discussion about the potential harm that can occur.  So we obviously need public education.  But beyond that we need to get organized with community efforts.

This will not be without controversy considering the "Death Panel" false scare and now an attempt by some to do away with the very useful POLST forms.  Each State and County Medical Society needs to participate in community wide efforts in education along with our legal colleagues, nursing colleagues, hospice workers, social workers, community activists, etc.

Hopefully the "D" Word conversations are beginning to take hold.  The next steps are to help folks understand the choices, talk to loved ones about values and choices, document them and make sure the documents are distributed to family, doctors, and a lawyer if you have one.  There can't be too much communication.  It's your life, and your choices - we owe it to ourselves and others to make our wishes known.

Sunday, June 30, 2013

Aid in Dying - Vermont's Unique Path

Vermont recently became the first state to enact a law authorizing physician-assisted suicide through the legislative process.  "As the governor signed the bill, Jean Mallary watched carefully over his shoulder. She’s the widow of the late Dick Mallary, a former speaker of the House and U.S. Congressman.  Mallary was in pain and suffered from terminal cancer when he chose to end his life over a year ago. Jean Mallary’s story about her husband’s choice – and that he had to die alone without his family at his side – was compelling personal testimony that pushed the bill forward."

I happen to live in one of the other two States which passed a "Death with Dignity" (DWD) law through the voter initiative process.  It's been pretty much a non-issue here in Washington State with no blaring media articles.  Only about one in 500 deaths are a result of utilizing our State's law.  The individuals I've talked to who have witnessed the deaths, have found the process humane and comforting.  A recent report in the April 11th issue of the New England Journal of Medicine gives the most recent data on the quite rare use of physician assisted suicide. "Washington's Death With Dignity Act hasn't lead to scores of terminally ill people seeking lethal prescriptions, the researchers report: Almost three years after the law was enacted, just 255 people had obtained a lethal prescription from a physician. Of those 255 prescriptions, 40 were written for terminal cancer patients at the Seattle Cancer Care Alliance. And, in the new study, doctors there found that only 60 percent (24 people) of their patients chose to use their prescription to hasten their death."

I must admit, however, that I still have some qualms about the potential for abuse of the Death with Dignity (DWD) laws.  So I've stayed neutral in my own stance, waiting to see how it plays out and trying to stay vigilant for the potential of abuse.  As more and more of us reach advanced age and the pressure to conserve health resources mounts, we need to make sure that the individual is making an autonomous well informed choice.  Also, we need widely available affordable health care for these very ill patients, plus superb hospice and palliative care.  The DWD option needs to be a "last resort" when very good care has failed to relieve or address the individual's concerns.

Fortunately the DWD laws in Oregon and Washington have been carefully crafted, monitored, and transparently reported.  To maintain their good record, it will require on-going funding and oversight particularly if the financial burden of health issues continues to weigh heavily on patients, families, medical institutions, and governments.

I have three areas of concern about Advance Care Planning.  First is the continuing lack of Medicare payment for end of life discussions with an individual's physician.  There is some hope that progress will be made by the United States Senate Special Committee on Aging.  It's certainly worth viewing this special Senate Hearing and reading reports from very the engaged Senators, plus representatives from Five Wishes, the Conversation Project, and the POLST Paradigm.

The second area of concern are media reports of abuses related to England's Liverpool Care Pathway where, at times, physicians may have written "do not resuscitate" without the consent of the patient.  Other abuses are under investigation as well.  The pathway, though well intentioned, has proven to be an area of controversy in its uneven application and implementation.

Thirdly, there is evidence for the misapplication and misuse of Washington State's POLST (Physician's Orders for Life Sustaining Treatment).  Some retirement communities in our area are "requiring" that all residents, even those in independent living, have a completed POLST form.  This is not the intent of POLST forms which are applicable as active medical orders for those in the last six months of life or the very frail elderly who are clear about their wishes.  So there are unintended consequences from some important efforts that need monitoring and updating to prevent misunderstanding or abuses. 

Tuesday, May 14, 2013

What's a "Good Death"? Three Interviews on NPR.

Recently I was interviewed on the local NPR radio station (KUOW) by producer Katy Sewall.  In the first of a three part interview Katy started out by asking me to describe a "good death".  Candidly, I had to struggle a bit with the answer, because "good" can mean different things to different people.  Basically it seems to me that if we, as medical providers, can adhere to the patient's wishes then they can pass from this world in a way that respects and dignifies them as a person. If interested, here is the podcast of the interview (it begins about 12 minutes into this Podcast and lasts for about 17 minutes:

A second portion of the podcast interview which is more focused on medical interventions is available.  It starts about 27 minutes into the segment:

The third portion deals with "Religion and the Doctor" - one of my blog posts.  It starts about 27 minutes into the podcast:

Thursday, May 2, 2013

Videos of CPR Aid Informed Consent

When my Dad was 94 years old and in a nursing home in western Pennsylvania, I got a call from my sister, "Jim, Dad's losing weight and seems to be withdrawing.  I'm worried about him.  The doctor's doing some tests today."

Well, one of the many tests turned out to be a chest and abdominal CT scan.  His heart was enlarged (we knew that from his history) and everything else was normal except for a 1cm spot on his left kidney.  Whether this was benign or malignant was clinically irrelevant but my sister was worried.  "Shouldn't it be biopsied or removed?"

I replied, "I don't recommend that.  It couldn't be causing his lack of appetite or general dwindles.  Even if it is a small cancer, it's very unlikely to ever cause him a problem.  A medical intervention may well harm him."

I had to pull some strings to set the direction toward comfort care, which is what he always said he wanted.  But what if I hadn't intervened?  Often, we almost mindlessly opt for more intervention, a diagnosis, a new drug, or a "life saving" treatment - even in a 94 year old trying to approach the end of his life in a dignified way.

There are a variety of attempts in our country to figure out the most effective way to have "the conversation" with patients and families about end of life values, options, and choices.  It's pretty clear that pamphlets, words, and discussions aren't enough by themselves.  Harvard physician Angelo Volandes has found that videos of things like dementia care and CPR may profoundly alter the choices that patients make.

In a calm manner Volandes' physician spouse, Aretha Delight Davis, presents factual data during the videos.  This visual learning appears to be much more powerful than verbal descriptions and may affect our choices on intervention.

It's nearly universally felt among physicians, that we're overusing the "technologic imperative" at the end of life - often depriving the patient the opportunity to die at home surrounded by loved ones and receiving support from hospice and palliative care.  As one patient told me, "If I wake up in the next life attached to tubes, I'll know where I've gone."

Saturday, April 27, 2013

The Physical Exam - a Lost Art?

Bobby was admitted to the hospital once again with overwhelming fatigue and shortness of breath. Yet this 37 year old farmer looked the picture of health. He grew up on a farm rising before dawn, milking cows and working long days in the fields with hay or corn. He was never seriously ill as a child and was a good football halfback in high school.

But this was his third admission for evaluation. He had been through heart and lung tests and even a psychiatric examination but everything was coming up normal. As is usual at a University Hospital Bobby's first "doctor" on that admission was Mike, a third year medical student who was being examined himself on his ability to evaluate a patient.

Mike spent about a hour going though Bobby's extensive chart: normal blood count, electrolytes, liver function, kidney function, calcium, and thyroid tests. The urinalysis was normal, as was the chest X-Ray and EKG. He had baffled the medical residents, research fellows, and faculty - so what in the world could he contribute?

Bobby told his story once again, "I feel OK when not doing much, but when I try to climb a ladder or haul some hay I just feel all in. There's no pain, but I just feel like keeling over." His treadmill test showed that he was limited, but no sign of coronary artery disease.

Mike noted this history at the beginning of his new evaluation, the "chief complaint."

"I'm going to ask you a bunch of questions you've probably been asked before, do you mind?", asked Mike.

"Not if you can fix me up, I don't want to die from this."

"OK, let's start way back. Tell me your story about growing up, I need to find all I can about you."

So Mike became a listener and Bobby began to tell stories from childhood, some of which we're pretty entertaining like tipping over outhouses at Halloween, once with a farmer inside!

"In fact, said Bobby, that guy was as mad as a hornet. We were running away, and I climbed over a fence, when he cut loose with his shotgun. Maybe he was just trying to scare us, but I took some buckshot in my rear."

For some reason, this intrigued Mike. He hadn't found anything in the prior records about trauma. "So what happened, did you need surgery?"

"No, but there were a bunch of skin holes and we only got out one or two pellets. It looked like I had chickenpox on my ass!"

Mike tucked this bit of information away and finished up with his hour long interview and taking of notes on family history, social history, occupational history, etc. He knew this was going to take hours to write up for his examiner. But as he was thinking, he couldn't get his mind away from the puzzle of the shortness of breath: it didn't seem to be heart disease, lung disease, or other organ failure, so what was it?

With an educated whim, Mike asked Bobby if anyone had ever listened to his bottom with a stethoscope. Bobby whooped, "Now wouldn't that be something. No nobody's touched my butt outside of my wife, that's for sure."

"Now Bobby this is going to seem more than a little crazy, but I'd like to check you there to see if the buckshot caused an unusual injury."

"Hey, Doc I'm desperate. If you think putting your stethoscope on my ass is the answer, then what the heck" said Bobby laughing.

With Bobby prone and rear exposed, Mike could see the multiple buckshot scars on the right buttock and thigh. He couldn't see any pulsations, but when he first placed his hand over the area he could feel a gushing sensation, which in medical terminology is called a "thrill' - perhaps a misnomer for trill. But it was a definite harmonic vibration with each heart beat. The stethoscope was next applied and revealed a very loud (grade 6/6) "murmur" - another strange medical term from the older lexicon.

Mike wasn't sure he had found the actual problem or, if so, anything could be done to fix it. The next day, on rounds with students, residents, and faculty zipping though the rounds with rapid file questions and orders they came to Bobby's bed. Bobby was beaming and couldn't contain himself, "Hey doctors, my bright young doctor here has found a murmur on my ass, how about that?"

Mike gulped, this wasn't how he had planned to present the problem. He did manage to give the gunshot history and detail the physical findings. At first there was skepticism by the junior staff that the findings were significant. But the senior cardiologist was savvy and recognized the brilliance of Mike's discovery. He said, "It's pretty clear to me, that this patient has high output heart failure. I would guess that he must be loosing 50% of his cardiac output to a shunt between a large pelvic artery and vein. He can function OK at rest but goes into high output heart failure with exercise because of the shunt."

Comment: That's how it turned out. Bobby's shunt was viewed with a dye contrast study and the vascular surgeons consulted. A large artery and vein had been joined together by the penetrating trauma of the buckshot. It was relatively straight forward surgery to close the shunt thus returning the blood flow to a normal pattern.

I wish I could say I was Mike in the story, but I was one of the many who missed the diagnosis. But I did learn that many medical problems can be uncovered by a good history followed by a detailed physical exam. As one professor said, "Listen to the patient with your eyes, ears, hands, and stethoscope."

In many ways physicians have mistakenly moved away from the comprehensive physical exam in favor of the high tech evaluations.  Abraham Verghese who is a Professor for the Theory and Practice of Medicine at Stanford University Medical School has reminded us in a TED video talk about the importance of touch, listening and the laying on of hands.