Saturday, September 24, 2016


       I had a chance to attend the lecture of Dr Atul Gawande, the famous writer who has written some books and the last one is BEING MORTAL. His lecture was recently arranged by Florida Hospital and being in medicine and quite familier with the topic , I decided to go . The lecture was attended by many ,the hall was full and he had standing ovation. I have known the mortality of life for long time and have seen the effects of aging in my patients and relatives and myself. So the topic was not new nor was the contains. But what I have found out in my own experience is that it is the most difficult task in medicine. So this is one of the two stories.
       I saw this 86 years old male in the hospital for shortness of the breath. He had high blood pressure and question of the heart problem . When I saw him he had some fever and cough and he was short of breath. His wife was in his room . His ability to walk was reduced and his wife had to help . She looked little younger than him , may difference of 10 years. So the chest X-ray was done and the diagnosis of pneumonia was made . He was treated with antibiotics . He also needed oxygen and some additional treatment. We also did the echo cardiogram and it showed some narrowing of the heart valves , some elevated pressure in lungs . At his age this was not unexpected . I often tell patients that as the doors in older house do not close tightly or get stuck , the doors or the valves in heart either become sticky and narrowed or leaky. I did swallowing test and it did show some problem , but he did not too badly. So improved and was discharged home .
      I saw him in the office and did the breathing test. It showed reduced lung capacity and so he was put on some inhalers to help open the bronchial tubes. He was readmitted with the congestive heart failure in next 2-3 months . He was treated and discharged , but this time he was weaker and needed physical therapy and needed to be sent in a rehab center for 2 -3 weeks . We repeated the swallow study as my suspicion was that he was aspirating food and liquids and so he was having the lung problem. This was worst and indeed he was aspirating. But the speech therapist thought that he may do OK with certain precautions. He was seen in my office and we did  check up on his need for the oxygen . He could walk short distance and his oxygen dropped . So we had to put him on oxygen . So I saw him in the office in next 4 weeks and he was doing OK . He needed to increase the flow of oxygen when he would walk. Higher the flow is needed , larger the oxygen cylinder is needed. The smaller ones would not last longer duration . So the choice is to drag the larger cylinder or don't walk much. Dragging larger cylinder foe 87 years old is not easy. SO then I talked to him about his expectations  and CODE STATUS.He told me he had not give a FULL THOUGHT and will talk it over with his wife and let me know .
     Two weeks down the road he was again admitted with another bout of pneumonia -most likely aspiration.I saw him and saw his CT scan and talked to him treatment and repeating the swallow study . I also told him that he may need feeding tube if the swallowing function is not normal and worst. He did not say much . So I again asked hin about CODE STATUS. I told him that he needs to make decision before it is too late His answers was same , ' I will discuss with my wife and let you know.'
    So if years old with all this problems can not make the decision then how do we expect younger one to do it? There are 3 other doctors involved in his care and not a single one has talked to him about this . May be if all of us in health care would talk at same wave length it might change , but who has TIME!!!!!! 

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