Today was a busy day, kept me running. My morning was occupied by making rounds on all of my patients again at the hospital. At lunch time I went to a lecture given by one of the physicians from the Poison Control Center in Washington, DC. Medicine is constantly changing, so it is important to keep up with journals, lectures and anything new that emerges. The topic was on a new substance of abuse that we are seeing in the community called “bath salts”. It is termed the “new ecstasy” and is a hallucinogenic drug that causes some individuals to become psychotic and violent – so their friends bring them to the emergency room. Interestingly I had just listened to a piece about it on NPR this morning. There are a handful of states, most of them in the south, where it is legal and is sold in convenience stores. Crazy…
After the lecture, I met with the 3 medical students who are rotating through our family medicine center this month. 1 is from Georgetown and 2 are from Virginia Commonwealth University. We spent time reviewing their patient encounter write ups that they are required to hand in to me, tweaking them to perfection, and reviewing their progress thus far. Fortunately all of them are doing well, so this was an easy part of my day.
I spent the afternoon at an assisted living facility for people with dementia where I am the medical director. I really enjoy my time spent there. The patients there are always willing to share a hug or smile. One theme that occupied my afternoon was the discussion of end of life care. This is always a touchy topic with families – most usually have strong opinions one way or the other. Here are a couple of illustrative cases.
First of all it is important to note that dementia is an unfortunate illness – it is always progressive. No one ever gets better. At this point we have medications to help slow the progression.
Case A – 83 year old female who has with dementia greater than 10 years. Has been slowly declining, but has had a recent rapid decline – barely eating, very weak, can’t walk without assistance. Her daughter and family have been working in Egypt at the Embassy, but were evacuated last week. I had a long discussion with her daughter and we decided to have hospice assist in the dying process to assure maximum comfort at the end of life. Her daughter needed reassurance that it was OK to not be aggressive and allow a natural death.
Case B – 87 year old female admitted yesterday. She has had years of dementia. She looks well, smiles, walks without assistance, but can’t answer a question as simple as “what is your name?” She talks, but incomplete sentences and nothing that makes any sense. She paces. She doesn’t watch TV, read or attend activities in the community center. Long discussion with her sons regarding goals of care, end of life issues. They want everything done no matter what – including CPR if she collapses. They feel her quality of life is good and we should do everything to keep her alive.
Case C – 99 year old female with mild dementia. She can converse and joke with me. She feeds herself, watches TV, plays games, walks well and enjoys her family. In reviewing goals with her son, treat things that come up, like pneumonia, but do not do CPR or life prolonging measures like feeding tubes when she declines.
So, these are just a few angles of this discussion, which is very heated, including rants about death panels with health care reform issues. What is my job here? I can never pass judgment or impose my views. My role is to listen, educate and support. I firmly believe in death with dignity and aiding families and patients in the process. People are often confused and think that DNR (do not resuscitate) means do not treat. It does not. It means do not do CPR, chest compressions, shocking and mechanical ventilation in the event of heart or lung collapse. I provide facts to help with decisions. Here are some statistics that I provide:
In the general population, 41% of individuals requiring CPR who have an arrest while IN the hospital survive the initial event.
13% will survive the hospitalization and be discharged to home. There is no data regarding functionality at that point.
A recent study showed that individuals over age 70 had a 31% initial survival rate from CPR, but about a 1% discharge rate from the hospital.
In the end, it is an extremely personal decision. Again, my job is to listen, educate and support decisions.