Three months in as an attending and one phrase I've found myself uttering at least once a week, "I'm sorry."
It seems like every week I review charts and come up with the conclusion that someone is very sick.
Now in today's hospitalist life, the acuity is higher and this is hardly something unexpected.
What I mean to say/feel is later confirmed when I go to the bedside.
We have a person , a patient whose quality of life is impaired by some condition or group of conditions. There is a reasonable expectation that they won't recover and their quality of life won't improve or was poor prior to entering our hospital.
Now the colder, unseen aspect of our job as doctors is realizing that someone needs "palliative" "goals of care" "hospice" "the talk" .
There almost a mental checklist that occurs before we step in the room for AM rounds.
Extensive end-stage comorbid conditions, age, functional status, frequent re-admissions, complex recent admissions and we paint a picture which more oft than not is supplemented at the bedside.
Now, I hope the readers don't view this objective/cold decision making on an extreme, some kind of allusion to "death panels", etc. This happens outside the room. What happens, is the human element.
Good Morning I'm Dr. Abdullah, you can call me Robert/Dr. Robert if that's easier to pronounce / remember.
How are you?
I'd like to summarize your hospital course (if I'm taking over service), please correct me.
-or- I've reviewed your chart and I'd like to summarize what I've read.
Usually, I'm fairly spot on (which is a testament to EMR and good colleagues).
And the conversation usually leads to some variety of the following question "so where do we go from here, how am I (or my loved one doing)?
At this point (in this particular entry) I have already realized they are not doing well.
I tell them that I'm concerned about a,b,c.
I don't see a,b,c changing.
Then I ask them to paint me a picture on a good day, a day before hospitalizations, before being confined to a bed.
Then we together contrast those things , the here and now and the best they've ever been.
At this point most patients and families can appreciate what I'm establishing.
The conversation may not conclude there.
I may request we allow time for interventions to work/not work.
I may ask them to discuss things together.
When I return, we discuss quality/goals. Here's where my approach has drastically changed.
Here's where my blog entry takes a very different turn.
I wasn't born a doctor and I don't envision myself as particularly gifted/talented in one fashion but I did experience something that changed who I am and how I care for others.
I was however born a grandson, the eldest in fact on my mom's side.
My maternal grandfather Tulsie Sookdeo passed away at Hospice on June 5, 2015.
He had concluded a struggle with pulmonary fibrosis.
I miss him so much and I realize that more and more each day.
He was diagnosed the latter part of 2014. When I was told by my mother, I attacked it like I attacked any diagnosis, any condition. I read anything I could get my hands on. I reviewed the literature, I talked with attendings I trusted. I reviewed the proposed medications his doctors were considering. I called his pulmonologist. I set with my fiancee, a fellow doctor (who was already an attending) and I reviewed his CT Scans.
Then it hit me. This is is not good. I know pulmonary fibrosis, this has a poor prognosis. There is not cure. This is not good, oh crap what am I going to tell my mom.
I asked his pulmonologist and he gave me a standard response of "let's see how he does with medication" but I knew the data. I knew that meds won't change mortality, they may help with some numbers, some morbidity but there is no cure.
My grandfather wasn't a candidate for a new lung.
Then things started to progress quickly, he was wearing oxygen and titrating it up.
He has sig. hypoxia with standing.
Towards the summer, he wasn't improving.
His multiple outpatient courses of antibiotics, his cardiac cath, his visits all pointed to worsening disease.
My mom called me and told me to call my grandfather and for lack of a better work reprimand him and have him go to the hospital. His oxygen was dipping to 70s with standing.
Within days of being admitted he was in ICU.
My fiancee and I saw him in the ICU.
I swung back and forth between being a grandson, hearing my grandfather's stories and him telling me how so and so "are idiots"
and then telling him that he has terminal disease.
I was alone at his bedside and I told my grandfather that he wasn't going to get better.
That was one of the hardest things I've ever done. I even talked with him about code status and goals, ultimately leaving prior to him accepting hospice care.
Things were stable-ish.
And then my life collided with itself.
On one hand I was days away from graduating a dual-residency , the culmination of 12 years of schooling/training (undergraduate, medical and residency) and enjoy a very selfish type of experience.
I had been following closely with multiple phone calls and Grandpa was not improving.
I got several calls from my sister and cousin and I was torn.
I didn't know what the right thing to do was.
Could I finish my work obligations and come to Florida as soon as I could or was there an imminent event.
I was very close to making the wrong decision.
I had been a doctor for four years, making myself available, coming in for others, sacrificing time for my job and I was torn.
I didn't know what to do.
Then I made a decision that answered the question "If I don't go, would I regret it?"
I made work arrangements and was on a plane within hours and at my grandfather's bedside shortly.
I walked so fast into hospice, most of my family didn't recognize me and my dad didn't even recognize I was there.
Then I cried and couldn't stop.
I had to leave the room, I didn't want my grandfather to see me like that.
The next days would be trying for my family as we saw the last bits of his personality fade.
His dyspnea, anxiety progressed and we escalated his morphine and ativan.
I stayed up all night with him at the bedside, with my sister the night prior to his passing.
I went to sleep for a few hours prior to Friday prayers when I got the call that my grandfather has passed, just minutes after the chaplain came to give a prayer.
My Grandfather Tulsie was one of the hardest working, intelligent, funny men I know.
His spirituality transcended any particular religious tradition.
I am the grandson, the doctor I am today because of him.
His last gift, a gift that I'd gladly given back [ to have him back] , to me was empathy.
Going back to my original entry.
I empathize with families.
I have told them that I understand.
I know what it's like to have to talk about comfort, quality of life, terminal illness.
I know how hard it is to want so so bad to believe in a miracle a chance of recover despite all your other intuition.
I understand the burden of wanting to bring someone home in their last days/weeks.
I tell them I'm "taking my doctor hat off" and I'm talking to you as someone who's been there.
I have teared up more than once talking to families like this, it makes me remember my grandfather and feel helpless that I couldn't cure him, fix him but it also lets me share some of their burden.
I tell families that I am here for them. They can call me. I will make sure their loved one is comfortable.
I tell them I don't underestimate their spiritual care, I will call a chaplain for them.
While I haven't been offered yet, I would pray with my families, regardless of their religion.
I hope to provide comfort , dignity in someone's last days.
I hope I am empathetic.
(Empathy is defined as the feeling that you understand and share another person's experiences and emotions : the ability to share someone else's feelings )
I hope that the comfort I provide for my patients is deserving of what you taught me Grandpa.
I wish I could tell you this in person. Your legacy lives on in my heart and every emotion I share with families.
I love you Grandpa.
For you (from a patient),
I beg of my readers (whoever is out there)
Family first. The rest of your life will go on, the job will go on. Don't live with regrets.
Cherish your health, if you are walking, talking, eating, drinking, you are already better off than many people.
Wealth is in the people you impact , not the things you possess (be it money, knowledge, material things).
