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Popping the Question

Mitch Kaminski

Mr. Dwyer isn't my patient, but today I'm covering for my partner in our family-practice office, so he's been slipped into my schedule.

Reading his chart, I have an ominous feeling that this visit won't be simple.

A tall, lanky man with an air of quiet dignity, Mr. Dwyer is eighty-eight. His legs are swollen, and merely talking makes him short of breath.

He suffers from both congestive heart failure and renal failure. It's a medical catch-22: when one condition is treated and gets better, the other condition gets worse. His past year has been an endless cycle of medication adjustments carried out by dueling specialists and punctuated by emergency-room visits and hospitalizations.

Hemodialysis would break the medical stalemate, but Mr. Dwyer flatly refuses it. Given his frail health, and the discomfort and inconvenience involved, I can't blame him.

Now his cardiologist has referred him back to us, his primary-care providers. Why send him here and not to the ER? I wonder fleetingly.

With us is Mr. Dwyer's daughter, Karen, who has driven from Philadelphia, an hour away. She seems dutiful but wary, awaiting the clinical wisdom of yet another doctor.

After thirty years of practice, I know that I can't possibly solve Mr. Dwyer's medical conundrum.

A cardiologist and a nephrologist haven't been able to help him, I reflect, so how can I? I'm a family doctor, not a magician. I can send him back to the ER, and they'll admit him to the hospital. But that will just continue the cycle....

Still, my first instinct is to do something to improve the functioning of his heart and kidneys. I start mulling over the possibilities, knowing all the while that it's useless to try.

Then I remember a visiting palliative-care physician's words about caring for the fragile elderly: "We forget to ask patients what they want from their care. What are their goals?"

I pause, then look this frail, dignified man in the eye.

"Mr. Dwyer, what are your goals for your care?" I ask. "How can I help you?"

My intuition tells me that Mr. Dwyer, like many patients in their eighties, harbors a fund of hard-won wisdom.

He won't ask me to fix his kidneys or his heart, I think. He'll say something noble and poignant: "I'd like to see my great-granddaughter get married next spring," or "Help me to live long enough so that my wife and I can celebrate our sixtieth wedding anniversary."

Karen, looking tense, also faces her father and waits.

"I would like to be able to walk without falling," Mr. Dwyer says. "Falling is horrible."

This catches me off-guard.

That's all?

But it makes perfect sense. With Mr. Dwyer's challenging medical conditions commanding his caregivers' attention, something as simple as walking is easily overlooked.

A wonderful geriatric nurse practitioner's words come to mind: "Our goal for younger people is to help them live long and healthy lives; our goal for older patients should be to maximize their function."

Suddenly I feel that I may be able to help, after all.

"We can order physical therapy--and there's no need to admit you to the hospital for that," I suggest, unsure of how this will go over.

Mr. Dwyer smiles. And Karen sighs with relief.

"He really wants to stay at home," she says matter-of-factly.

As new as our doctor-patient relationship is, I feel emboldened to tackle the big, unspoken question looming over us.

"Mr. Dwyer, I know that you've decided against dialysis, and I can understand your decision," I say. "And with your heart failure getting worse, your health is unlikely to improve."

He nods.

"We have services designed to help keep you comfortable for whatever time you have left," I venture. "And you could stay at home."

Again, Karen looks relieved. And Mr. Dwyer seems...well...surprisingly fine with the plan.

I call our hospice service, arranging for a nurse to visit him later today to set up physical therapy and to begin plans to help him to stay comfortable--at home.

Although I never see Mr. Dwyer again, over the next few months I sign the order forms faxed by his hospice nurses. I speak once with his granddaughter. It's somewhat hard on Mr. Dwyer's wife to have him die at home, she says, but he's adamant that he wants to stay there.

A faxed request for sublingual morphine (used in the terminal stages of dying) prompts me to call to check up on Mr. Dwyer.

The nurse confirms that he is near death.

I feel a twinge of misgiving: Is his family happy with the process that I set in place? Does our one brief encounter qualify me to be his primary-care provider? Should I visit them all at home?

Two days later, and two months after we first met, I fill out Mr. Dwyer's death certificate.

Looking back, I reflect, He didn't go back to the hospital, he had no more falls, and he died at home, which is what he wanted. But I wonder if his wife felt the same....

Several months later, a new name appears on my patient schedule: Ellen Dwyer.

"My family all thought I should see you," she explains.

She too is in her late eighties and frail, but independent and mentally sharp. Yes, she is grieving the loss of her husband, and she's lost some weight. No, she isn't depressed. Her husband died peacefully at home, and it felt like the right thing for everyone.

"John liked you," she says.

She's suffering from fatigue and anemia. About a year ago, a hematologist diagnosed her with myelodysplasia (a bone-marrow failure, often terminal). But six months back, she stopped going for medical care.

I ask why.

"They were just doing more and more tests," she says. "And I wasn't getting any better."

Now I know what to do. I look her in the eye and ask:

"Mrs. Dwyer, what are your goals for your care, and how can I help you?"


About the author:

Mitch Kaminski is a family physician who has practiced, taught and led in primary care for thirty years. He is the medical director for AtlantiCare Physician Group in southern New Jersey. "Our technologically advanced medical system, which is oriented towards treatment and cure, often forgets to address the patient's goals of care. As a provider, there is no easy time to acknowledge the end of life with a patient. I have come to realize that, especially with an elderly patient, any discomfort about the talk comes more from me than from the patient or the patient's family."

Story editor:

Diane Guernsey

 

Comments   

# Richard Tsou 2015-03-17 02:12
Great article Mitch! You have really struck a nerve with anyone involved in Pt care. Proud to say I knew you back when we were young students. Even then I always thought of you as a kind, caring, thoughtful person. Didn't know you
ended up in family practice... Obviously a good fit!
Wendy and I remember you well from Bates 2,
GO BLUE!!
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# Mitch 2015-03-29 17:11
Richard
how great to hear from you. Thank you for the kind words.
email me at if you'd like for more updates. Hi! to Wendy.
Mitch
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# Leeny2 2015-03-14 14:57
Dr. Kaminski and everyone might want to read Dr. Atul Gawande's excellent book, "Being Mortal". You can watch a Frontline episode on it here: http://www.pbs.org/wgbh/pages/frontline/being-mortal/
Gawande's article, "Letting Go. What should medicine do when it can't save your life".
http://www.newyorker.com/magazine/2010/08/02/letting-go-2
I also recommend this site for starting the conversation about end of life care: http://theconversationproject.org
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# Chandra 2015-02-19 16:23
What a beautiful story. This brought tears to my eyes. Thank you so much for sharing.
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# Leeanne Dove 2015-02-15 19:12
As an aged care nurse I want to say a huge thank you for recognising the rights of the patient to determine their outcomes. So often in a desire to heal, the elderly are subjected to endless tests and treatments that don't give them the quality of life they long for. Well Done!!
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# Jayme 2015-01-28 21:05
Brought tears to my eyes.
This story reminds me when I was a 3rd year medical student and I worked with an amazing cardiologist. He would discuss "do not resuscitate" with his elderly patients and if that is what they desired (most do) he would sit with them to sign the form. One of the kindest, most humble physicians I know. Thanks for joining that cardiologist down this much needed road.
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# Kathy Hill 2015-01-27 09:15
Mitch, very eloquently put. It is so important to ask this question of all patients, but especially important for the medically complex who can easily be pulled down high tech super highways because algorithms send them there. In a pay for performance world, thank you for reminding us that patients personal goals matter. You have made me proud.
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# Kathleen Schwarz 2015-01-26 15:36
I like to start my meetings with patients with the question, "How can I help you?" I think of all the time saved with what does NOT need to be discussed, like which doctor said what, how long were you in the hospital, etc. It also suggests my willingness to try and help, which is a different introduction to a healing context.
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# Jaclyn Nguyen 2015-01-21 01:12
Beautiful, beautiful, beautiful!
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# Susan G Weiss 2015-01-20 14:03
Couldn't be more timely, and correct. Relevant article recently published in the NYT, http://nyti.ms/1DUWHQ2 and also read "Being Mortal" by Atul Gawande, http://atulgawande.com/book/being-mortal/

You gets two thumbs up from me, Dr. Kaminski.
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# LYN T GARDNER 2015-01-20 10:34
AWESOME! I hope to be treated the same way when I get to that point in my life! What a wonderful doctor and caring physician! :)
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# Genevieve Minick 2015-01-19 22:29
Thanks for this story, I recently saw a sweatshirt that said I'm a Family Medicine Physician because Totally Awesome isn't a recognized job title- Mitch, you ARE totally awesome! We all need reminders to take that breath and look the patient in the eye and ask "what are your goals for your care, and how can I help you?"
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# Kohar Jones 2015-01-19 12:14
Beautiful. The simple, difficult questions:
What are your goals for your care? How can I help you? Thank you for the powerful reminder.
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# Chuck Joy 2015-01-19 10:49
A nice illustration of learning effective medicine. Shared Decision-Making and Empowering the Patient come to mind.
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# Danielle Calvano 2015-01-19 08:03
Thank you Dr. Kaminski for sharing such a wonderful yet simple message. More clinicians should have the insight and empathy that you have. Your patients are lucky to have you!
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# Carol Santalucia 2015-01-19 07:45
Beautiful story, and a great lesson! Thanks for sharing.
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# Julie Evans 2015-01-18 14:17
What is so wonderful about this story is that Mitch didn't do anything extraordinary. He just asked a simple question and listened to the answer. It isn't complicated to care for people its just natural to want to relieve suffering. Good job Mitch in showing up as a caring human being who knows how to practice medicine.
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# Amy Crawford-Faucher 2015-01-18 13:21
And THIS is why we are family doctors. (And I think I know the wise NP to whom you refer!)
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# Yehudit Reishtein 2015-01-18 10:50
What a wonderful story--you took the time and invested the thought necessary to help this man (and later his wife) with what they really needed. I am sure the story did not stop here, but that you have continued to help patients live until the day of their death, not just to exist from one treatment to the next.

I hope many health care professionals get to read your story and learn from it
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# Harry L Chaikin, M.D 2015-01-17 17:51
As a physician working with our hospice service I had the opportunity to share this story during our interdepartment al team meeting. It was thoroughly appreciated by all--nurses, social workers, chaplains, and other members. Mitch's anecdote helps me to more than ever appreciate how our state POLST form was created with the first question being what are the patient's goals before concentrating on the specifics of their health care directives.
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# Gail crawford 2015-01-17 17:14
Thank goodness for physicians like you, Dr. Kiminski. As a former palliative care nurse, I know how few physicians have the courage to relinquish the comfortable routine and risk the unfamiliar. This is not a criticism, rather an acknowledgement that all of us can learn from those who have mentored us and helped us find the words that heal in a different but equally effective manner.
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# Julia Hallisy 2015-01-17 15:53
Thank you for this incredible post. The specialist likely referred the patient back to the primary care doctor hoping to accomplish exactly what happened. It is vital to establish ongoing, respectful relationships between patients and their primary care providers to facilitate conversations that can focus on the unique goals and wishes of each individual. Being open and truthful with patients about what treatment may be capable of improving and the health issues are not going to get better is vital in providing true decision support. The patient will almost always lead the way if they know the truth and feel supported in voicing their wishes.
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# Andrew Gallan 2015-01-17 13:15
"We forget to ask patients what they want from their care. What are their goals?"
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# Donald McKay 2015-01-17 12:25
Today, like many, is a busy day. In an attempt to free up some time, I almost pushed the 'Delete' key on this issue of the Pulse without reading it. Had I done so, I would have missed this compassionate and moving story from a reflective and caring physician.
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# Ron Banner MD 2015-01-17 11:41
Dear Dr. Kaminski,

Your story touched and moved me. I read straight through until "Several months later, a new name appears on my patient schedule: Ellen Dwyer" - when I began crying.

Too bad for medical students (and medical care) that they do not get to have regular doses of you.
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# Tuyet Phan 2015-01-17 00:55
Doctor are always people who helped them through the comfort , care, and concern,but patient when they know that their life is no longer ,they are not eager to attent treatment, they just want to stay close relative last hour , so Mr. Dwyer died peacefully. Thank to you Doctor ! Whether in the circumstances can make patients feel comfortable !
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# Laurice Gilbert 2015-01-16 23:31
I really love this story, as it mirrors my father's illnesses (CHD and kidney failure). Shunted between specialists, who were all caring in their own way, never asked what he wanted from them. Fortunately, he talked to his family, got plenty of auxiliary outpatient care, and was able to die (of melanoma) peacefully at home.

I'm not surprised Mrs Dwyer came to you. Listening to the patient's real wishes is highly under-rated.
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# Pris Campbell 2015-01-16 19:16
You're a wonderful doctor. Too many forget that simply prolomging life with difficulr procedures isn't anywhere close to what their patient wants or needs.
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# Stephanie Friedman 2015-01-16 19:07
A beautiful story, simply told. Or should I say, a simple story, beautifully told? Either one works. Some conversations are so simple, but not easy to initiate. Dr. Kaminski gives us the template--an honest, direct question that is enormously helpful to the patient. Thank you for this story.
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# Carol Lobel, R.N. 2015-01-16 18:55
excellent; insightful, practical, personal advice. wish more physicians would follow your lead.thank you
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# Donalea Deines 2015-01-16 18:41
Excellent article that will encourage we non-medical people to talk frankly with our family and our doctors and nurses about living out our last days naturally and eliminating the guessing game which agonizes medical personnel who wonder if they've made the correct moral decision.
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# Peg Ackerman 2015-01-16 18:29
What a wonderful story. Mitch went out on a limb and out of his comfort zone and really addressed the needs of this patient, allowing him his dignity. Obviously a very caring physician. At 88, this gentleman was just waiting for someone to initiate this conversation and thankfully Mitch did. Because of that, the patient died with dignity and comfortably. We all must remember that death is a natural process and allow patients to exit gracefully.
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