Two Ears, One Mouth

 We have two ears and one mouth so that we can listen twice as much as we speak. Epictetus

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I think it's a fairly common practice for doctors, at any level, intern, resident, attending to carry some kind of paper around. The more senior you are, the less you carry I find. This paper has patient names, perhaps jotted down conditions, and to do items. It might be folder hot dog style and tucked in a white coat pocked or event folder in four and tucked in a scrub pocket. 

But let's think about the to-dos 

When I'm on service, I definitely have a jotted list of to-dos or mental task list. Things like: narrow antibiotics, call pt's family, discuss goals of care

I'd like the thing that my first meeting is more , personable. A hi, how are you going, how was your night?  But given time constraints and a constant sense of throughput, we have to move things along.

Mr. Crag (not his real name) was an ICU downgrade to the general floor. A quick skim through the chart and I see advanced cancer, not a candidate for tumor directed therapy, was in ICU for septic shock , downgraded and then back to ICU for hemorrhagic shock. Sounds.. not so great.   My gut check, my gestalt was oh boy this gentleman sounds sick, part of his care plan is going to involve goals. 

But my nature is not to jump right in. It takes me a good 24 hours to digest a case, understand it and then melt it to the rapport I build with a patient/their family.

Very quickly into become his attending with my team of residents. My subspeciality colleagues emphasize the need to have a hospice discussion , the futility in certain interventions. This was a Friday, so any big moves would happen then or would fall upon me on the weekend.  In some ways, it felt like a forgone conclusion that Mr. Crag would die from his cancer and aggressive interventions, escalation would be futile, further investigations would be futile. Multiple goals discussions had occurred including in the ICU setting so I felt in some ways, who am I to questions the flow of the stream. I would be an agent of this discuss. Mr. Crag did develop bleeding so I asked him when/how can I best engage him and his support system in  a way that takes his preferences into consideration. He said his wife and sister (a nurse) would be available tomorrow, I said great.

So I thought okay, we set a time, the weekends are somewhat controllable and I'm comfortable having a conversation with three people (patient, his wife, his sister). I would lean into discussing DNR/DNI, hospice given above.

Come Saturday. Curveball.

As I'm rounding on my other patients with my senior, I see multiple family members at bedside. We had set a mutual time of 1pm but very quickly I was approached by Mr. Crag's niece (who I would later learn is a lawyer) who said they're all here for two meetings, one at 11am and one at 1pm. She wanted to know if all the specialists would be present, as well as pt relations.

Now.. I was confused.

Mr. Crag was of sound, we set a specific time and audience. 

Frankly.. I was  a little miffed.  

How did a 1pm meeting with three people become a full on family meeting with multiple family members in two parts with one part being a hospice discussion, and patient relations??

Now I'm not early in my career per se so I asked that we adhere to 1pm, engaged patient relations to meet with family first and explained that I'd be the only team in attendance but having engaged recently with the specialists I could speak to their opinions. 

After digesting this, talking to patient relations before our meeting about concerns. I decided to go empty slate.

I first drew attention to the large crowd , expressed my slight surprise to Mr. Crag, being open that things had changed but asked his permission first if he'd like a big meeting and second expressed my appreciation for their support.

I then listened.. and wrote , and wrote a lot.  I did speak to speak to my speciality colleagues inputs, having talked with them before.

I negotiated an agenda, to do list for the weekend, things we the medical team can work on that are of concern to family.

Then we came to more testing. As mentioned before, more testing/more imaging was felt to be of limited value. The case complexities are a bit nuanced, but the conclusion was that Mr. Crag will bleed from his cancer , what will more imaging show.

However, instead of saying no. I explained I'd consider it. I wanted to be clear that imaging may or may not show a cause and we may or may not be able to intervene. 

I also confirmed out list of to do item.

Lastly, I asked permission to share, to share my experience in navigating complex/ end of life discussions. I wanted to remind everyone, perhaps mostly myself, that we are talking about a person, a member of his family (uncle, husband, brother, etc).

The meeting concluded after an hour,  a lot of tension lifted. There was  a mutual exchange of appreciation for one another, me for his family being a voice and them for me listening.

Ultimately , I did get a CT scan and we did identify something that could be intervened upon and was intervened upon by interventional radiology. The patient stabilized, left the hospital (not on hospice) and was able to remain in the community , see his doctors in follow up.

Of my my specialty colleagues actually caught be one day and remarked, hey I saw you got that guy home and found x, y, z. 

When I think back on it.. I didn't really find anything... in a sense.

I could have just towed the line.. leaned on a conversation about advanced cancer, futility, hospice.

However, Mr. Crag was a scientist and his support system were educated, strong advocates. I listened , we created an agenda and tackled the problem in front of us. 

The clinical part was teasing out what was reasonable and being transparent on what outcomes may come.

The human part.. perhaps the most important part, was listening.

Mr. Crag and I shared several .. human moments after that. We talked about spirituality and medicine. He shared how supportive he felt by chaplaincy and expressed his appreciation for me listening. I expressed my appreciation for his patience and acknowledged how loved he was.

This is not to say that Mr. Crag's cancer just went away nor that he likely will have complications related in the near future    but it's more  to challenge the agenda, the inertia that's so easy to slip in to and to have honest, transparent, two way communication, so it becomes a "we" vs. an "I think we should or you should"

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This all comes in reflection after my last service week had deaths that came in three. 

I know that sort of saying, things come in threes but I can't say I've had three back to back cancer/hospice deaths.

Each experience was incredibly intimate, personal, as hospice cases can be. While as an inpatient doctor, I meet people in a very brief window of their life/health, it's often an acute/catastrophic sort of event.

My first death, a woman who had pancreatic cancer, having lost her own mother to pancreatic cancer. Every day tended by her devoted son (who she told our team, she has absolute trust in) and husband. The son worked hard to get his mom to yet another clinical trial but the cancer's progression and state was such that she missed her enrollment appt and transitioned to hospice , ultimately passing . The son told me, his mom is his world and he just wanted to make sure he did everything possible but wanted to ensure above all that his mom doesn't suffer.

The second,a family of physicians. The patient himself a physician. He succumbed to liver cancer. His struggle, or rather his family's struggle being so close in their lens as doctors was ensuring he didn't suffer and we didn't withhold anything inappropriately like nourishment/hydration. For those familiar with hospice, end of life care. Hydration, nutrition can be harmful ,prolong suffering and isn't needed in a body that has little demand/need for those things. However, culturally, intrinsically, this idea of water.. food being core to life.. always elicits this strong tug. In this case, I felt it was important to be concrete in my feeling they weren't of benefit but be willing to listen, troubleshoot, answer as many times as needed. At the end of the day, families don't want to reflect on their loved ones with guilt. 

The last case, GI cancer. Advanced presentation, large abdominal mass. She underwent some therapy but came in with acute obstruction. In her past life, she was a caretaker and advocate for people. Not formally a clinician or social worker but found herself advocating for people, interfacing with doctors on their behalf. Her struggle, at end of life was autonomy. Her disease took that away from her. 

Ultimately , we transitioned to a comfort approach but she was hesitant with "hospice" care. 

She felt it equalled less care.

I was clear in my belief, in many ways, it's more focused care. I speak from experience in that treating a UTI for example...clear cut.. abx, follow cultures.

With end of life care, there are nuanced to symptom management, comfort, support of patient/family, interdisciplinary care.

What I proposed was we intensify her care to comfort measures, let her lead based on symptoms and consider hospice only if they could match what we were doing. She also allowed my to have her family speak to hospice.

She ultimately passed on hospice care, comfortably with medications and having had a window to play with her grandkids, her youngest celebrating a birthday during her time in hospital. What I think was most humbling was by making her symptoms, her wishes priority, she was able to lead as opposed to us troubleshooting all these complications of her cancer (bleeding, clotting, obstructing). 

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I want to end with a comment.

I've gotten into the habit of telling my patients, it's important I am transparent/honest.

I am concerned with...

I worry that..

Sharing this is not my attempts at swaying them one way or another but it's important that they are informed..

An extension of this includes an honest dialogue about what potential outcomes might be after a cardiac or pulmonary arrest.

A very young, fresh out of residency attending used to boast "oh i'll make this person a DNR/DNI but end of day"

A more seasoned me feels we should be transparent with our concerns/fears with our patients and their families. Nobody likes surprises.. at least in the hospital setting.  

Very recently, I had a gentleman with metastatic melanoma, very sick. I met him on the order of minutes , this was a Sunday afternoon , my hospitalist group switches on Monday but I had one of these conversations with him and his sig. other.

He didn't change his code status or direction of care but his sig. other certainly understood our concerns.

He would pass a few days later , very sick  in the ICU, several conversations between mine and his passing. 

This serves as a reminder to me.. my goal and intention wasn't to "make him DNR/DNI" or change his goals.. but to express concern and this conversation evolved over time.

--i'll end there--   1 more day before I'm back on service.. and i'm sure i'll be having these sort of conversations...