Tuesday, March 20, 2012


    Sometimes we are in a situation, that we as doctor don't know  how to handle it. If we tell the truth, we look like 'heartless ' doctors who do not care. . If we avoid telling the poor prognosis, we continue to do tests after tests that are of no use to the care of patient. So we continue the futile care and add to not only the cost but to the heightened unrealistic expectations . At this stage it becomes difficult to talk to the family , and explain the futile care especially if you have not seen the patient before and so don't have rapport with them. Some doctors handle it very well and others don't. All of us develop our own style.  Those of us see patients in ICU, we face these situation quite frequently.
     I was called to someone who was transferred from another hospital . His  cardiologist had called me about this patient . He was 75 years old patient who was diagnosed to have congestive heart failure. But in last 3 months he had gotten worse , with increasing shortness of the breath, and more cough . Increase in 'water pills' to treat this had not helped. This got so bad that he was admitted, and then patient was put on respirator, and I got call and he was transferred to bigger hospital, and I was called in .
     I saw patient, and spoke to the family . (This story is 25 years old, when cardiology tests that are now  easily available were not there. )The cardiologist, who was also their primary doctor had send all the records and in fact I had lot of information, which is usually not there when patients are transferred. When I looked at his x-ray I realised that we may not be dealing with congestive heart failure ,but patient may have 'pulmonary fibrosis ' , scar tissues , which can mimic heart failure. I am not saying that patient did not have heart problem , but the worsening was due to worsening fibrosis. Thia means that HE MAY NOT IMPROVE . I realised that I have to buy some time to see if my thinking was correct. So I continued to watch him and I as I expected he did not improve. I continued to talk to the family, and slowly told them about the fact (as I saw ) that main problem was not heart failure , but the scar tissue and it is not likely to improve. This did not go very well . They were very agree, that the diagnosis was missed and he was not treated and now he was dying.
      His condition continue to get worse, and the need for oxygen continue to get worse. Time had come to talk to them about the fact that he may die , in spite of all the treatment and may we need to consider stopping all the aggressive treatments and make him ' comfortable '. This was a bombshell , they all stared shouting and were very angry , not only at the situation but also at the cardiologist who had missed the fibrosis, which was 'obvious ' to me . The things were going out of hands . I had to SOMETHING. I decide to do some thing unusual . I asked them to answer a question .I said , "Let me ask a question. When your father dies  where do you think he will go  ? "  ' What do you mean  ?'   " exactly what I asked , where do you think he will go , after death ? " I got the expected answer , 'off course with the Christ in the haven. ' I looked at them each one in the eye and slowly said , " Is it that bad that you are all shouting and fighting and blaming everybody  ?"
     There  was a pin drop silent. I had no problem making him 'comfort care ' and he died . The family had no problem accepting it .

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