Palliative Care

Lloyd Graham was given

Lloyd Graham was given excellent Palliative Care at St. Peter's in Hamilton.

http://well.blogs.nytimes.com

http://well.blogs.nytimes.com/2014/02/20/the-lies-that-doctors-and-patients-tell/?_php=true&_type=blogs&_php=true&_type=blogs&ref=health&_r=1&

The doctor-patient relationship is ideally an intimate partnership where information is exchanged openly and honestly. That is seldom the reality, however. Deception in the doctor-patient relationship is more common than we’d like to believe.
Deception is a charged word. It encapsulates precisely what we dread most in a doctor-patient relationship, and yet it is there in medicine, and it often runs both ways.

Dr. Sandeep JauharI once took care of a young woman who told me she suffered from a rare blood disorder that caused clots to develop in her heart and lungs. She’d had multiple surgeries, as evidenced by the scars on her back and abdomen. However, when we called her grandmother to get more information about her illness, she told us that her granddaughter was just fine — physically. It turned out she suffered from Munchausen syndrome, a psychiatric disorder in which patients intentionally produce or distort symptoms because of a need to be seen as ill or injured. They will undergo painful tests or diagnostic procedures if necessary to maintain the lie.

Physicians sometimes deceive, too. We don’t always reveal when we make mistakes. Too often we order unnecessary tests, to bolster revenue or to protect against lawsuits. We sometimes mislead patients that our therapies have more value, more evidence behind them, than they actually do — whether it was placebo injections from my grandfather’s era, for example, or much of the spinal surgery or angioplasty that’s done today.

Perhaps the most powerful deceptions in medicine are the ones we direct at ourselves — at our patients’ expense. Many physicians still espouse the patriotic (but deeply misconceived) notion that the American medical system is the best in the world. We deny the sickness in our system, and the role we as a profession have played in creating that sickness. We obsessively push ourselves to do more and more tests, scans and treatments for reasons that we sometimes hide from ourselves.
Despite thinking about these issues for much of my career, I am not immune to this sort of masquerade. Several years ago I took care of a woman with a severely leaky heart valve that was constantly putting her into acute heart failure. She was one of my most beloved patients who, at 88, and despite the ravages of her disease, always wore a powdered face, thick lipstick and salon-done blondish hair sitting on bony, wasted temples. She called me several times a week to update me on her condition — or sometimes just to chat.

So it came as a shock when I learned one afternoon that she was in the intensive care unit. She had been brought in several days earlier by ambulance to the emergency room, intubated with a breathing tube because of respiratory arrest and admitted to the I.C.U. with a diagnosis of worsening multi-organ failure.
I went to the I.C.U. for three straight days to check on her. Though she was sedated and breathing with the aid of a ventilator, her lips would curl upward in a smile whenever she’d see me. Her skin was jaundiced, a sign of liver failure. She had kidney failure, too, and had stopped making urine.

On the third day I went to see the attending physician, a colleague in his late 40s, to press him about why more wasn’t being done for this patient. Wouldn’t she benefit from dialysis?

He told me no, that she was at the end of her life, and laid out the reasons why dialysis would be futile and inappropriate.
I pressed him to reconsider, but he would not budge. Storming back to my office, I didn’t know what to think. Was my judgment being clouded by sentiment? Was I trying too hard to save my patient? Or was the I.C.U. physician not trying hard enough?
Two days later I took the unusual step of transferring my patient to the cardiac intensive care unit, and took care of her myself. Her sojourn there was a disaster. She was unable to be weaned from the ventilator. Her liver failure worsened. Even as it became clear to me that she was going to die and that my aggressive interventions had been for no good purpose, I became very reluctant to change course.

We checked blood tests several times per day. I inserted a pressure catheter in her pulmonary artery to monitor her hemodynamics. I started her on continuous veno-venous hemodialysis, but the dialysis catheter repeatedly got clotted due to low blood pressure. The breathing tube remained in her throat till the end. Eventually she succumbed to multisystem organ failure and sepsis, nearly a week after I’d transferred her to my care. She was 89.

At their core, my actions were a kind of deception — convincing myself, despite all the evidence, that I could save her, stay the inexorable course of her disease. Perhaps I was afraid of failure, or embarrassed by my impotence. Those last few days of her life she almost ceased to be a person for me. She became an experiment, a puzzle — one that I desperately wanted to solve.

Today, when I think about end-of-life care in America, I often think of my patient and my deluded response to her illness. In the end, we all practice a certain amount of self-deception. But when it originates in the doctor-patient dyad, patients are usually the worst victims.

Sandeep Jauhar, a cardiologist in New York, is the author of “Intern: A Doctor’s Initiation” and the forthcoming memoir “Doctored: The Disillusionment of an American Physician.”

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