Sunday, September 30, 2007

Getting used to palliative patients might take some time.

For our clinical skills classes, we spend most of our time on actors / standardized patients, who come into our clinical skills training rooms at the hospital and we learn how to do basic exams on them.

However, the odd time we'll go onto an actual hospital ward and get the opportunity to examine symptomatic patients.

Last semester we were at the hospital practicing our cardiac exams on a couple of hospitalized patients. My group was assigned a patient who was really friendly, and such a great sport - she didn't complain once about the four medical students percussing and auscultating her chest, tapping for a lung here, listening for a murmur there, asking her to sit up and lie down, even though it was obvious that due to her bad back the ordeal wasn't entirely pain-free for her.

Over the twenty or so minutes we spent at her bedside, she told us more and more about her condition, but she also talked her life - her job, her family, and the things she enjoyed doing before she ended up in the hospital. She wasn't too old, and she was pretty coherent. She seemed like a really nice lady, and I really enjoyed the chance to get to know her.

After our exam, we went to the nurse's station with our physician tutor, who called up the patient's lab tests and CT scans on the computer. We talked a bit more about the patient - she had a few other conditions that weren't related to our cardiac exam which we briefly talked over - and then were ready to move on to the next one, when the doctor said something that hit me like a truck.

"So that's Mrs. Walters. With all of that going on in her body, she doesn't have much longer to live."

I was shocked. I had just spent twenty minutes with this patient. She seemed to be functioning cognitively pretty well, and I figured she was in the hospital getting fixed! Never in a million years would I have thought she was about to die.

The seriousness of her situation started to set in, and from a medical perspective I realized that yeah, if I had been given this patient as a narrative case, I probably would have figured out that the prognosis was dismal. But because I met the patient as a person first, and didn't know all the details of her condition while I was talking to her, I hadn't really thought about what her prognosis was. Even while our tutor was going through the patient's chart, listing her conditions, the impending outcome of the sum of her conditions never hit me until the doctor put it into those words.

I suppose that now that I think of it, I might as well get ready for my clerkship year next year, when I will be meeting dozens of patients on a regular basis - some of them who don't have much longer to live. I've never really been in that situation before, and I think it's going to take some getting used to.


Christian Sinclair said...

You have learned a great lesson in medicine today. Know the patient as a person first. This will provide you with amazing stories and connections with patients you will never get from looking at millions of lab reports. It is the primary way you can realize you are helping someone, even when they are dying. If this happened pretty recently, you may even want to think of going back to visit her, or even writing a thank you card. It won't take long an will remind her that even as she may be dying she still was important to somebody, even a relative stranger.

Great post!

Anonymous said...

I agree with the comment above.

I would add: All of your patients are going to die some day. At some point you will not be able to "fix" them. There will be times when the end is sudden and unannounced, and you won't even see it coming.

The practice of medicine will be more rewarding if you make a point of getting to know your patients now, while they're still healthy. I don't know that this will make the crises and the deaths any easier to bear, but you will most surely be helping your patients if that relationship can be established sooner rather than later.

Really good post!

Anonymous said...

I have to agree with the above comments.
Having been a patient examined by med students, I have to say I actually enjoyed the process. I learned along with them. I also enjoyed watching them learn and seeing the light bulb moments....


Anonymous said...

Although actually acknowledging death as a reality of life and medicine is not the easiest, my time spent with palliative patients and their families, aiding in planning and carrying out "palliative/death plans", has been some of the most rewarding and engaging experiences in my short career thus far.
Not everyone, including those who are dying, views death like Hollywood; some are even able to laugh or go on a last vaca with the fam.
When palliative patients, whether imminent or those with a longer trajectory, engage with their caregiver and you with them, it is like being invited into a sacred space. Along with family and friends, you are permitted to experience the awe and amazement of preparing for death.
Having been at both, it is as beautiful and intense an experience, as being present at the start of a new life.

Anonymous said...

Thanks for keeping an open mind about palliative care. May you continue to appreciate the soul of your patient as you examine his/her individual systems.

Many palliative care practitioners understand that most patients know when they are dying, and they wonder why their doctors do not. Your patience, curiosity, and compassion will surely lead you to make good end-of-life care decisions for your patients.

Best wishes to you in your studies.