Providers are just as guilty of missing the big picture as patients and families.

Mr K, 78 yrs old, has long been dealing with multiple health issues.  His everyday life consists of treatments for diabetes, coronary artery disease, congestive heart failure and chronic kidney disease.  And about a year ago, he was diagnosed with early stage Alzheimer’s dementia.

Recently though, his family has noticed a definite decline in his cognitive function- he is increasingly forgetful, is less active, and now dependent on his family for everyday activities.

A week ago, he was hospitalized due to severe shortness of breath- and was diagnosed with a myocardial infarction (heart attack).  Mr K was critically ill and required intubation and admission to the ICU.

The cardiologist recommended a cardiac catheterization to determine if emergency coronary artery bypass grafting (CABG) or possibly (but less likely) coronary artery stenting would help.  But this was not a straight forward decision.   The dye used during the procedure would likely tip him into full blown renal failure, and he had previously said he would never want to start dialysis. Plus, because of his multiple co-morbidities, even prior to his heart attack he was at high risk for any operation, let alone CABG surgery.  After much discussion, his family declined the cardiac catheterization, and they opted to continue with medical management alone.

Along with the intensivist, multiple specialists including two cardiologists (one a heart failure expert and the other the interventional cardiologist), a nephrologist, and a neurologist were involved in his care.  After several days, although Mr K was at times more awake, he remained quite ill.  He still required the ventilator to breathe, and there were subtle signs that his condition was more likely going to decline, rather than improve.  After a frank discussions with the intensivist, Mr K’s family made the difficult decision to transition to comfort focused care- i.e, the ventilator and feeding tubes would be withdrawn and he be would be kept comfortable, and allowed to die a peaceful death.

After removal of the breathing tube, Mr K surprised everyone.  He was more awake and interactive than he had been at any time during the hospitalization, and he and his family had a wonderful day together.  As the evening progressed, not surprisingly he became more tired.

Sometime overnight, Mr K was transferred out of the ICU to the general care floor.   And the next morning his condition had declined dramatically-  he was somnolent and almost impossible to arouse, and most troubling, he seemed quite uncomfortable, with signs of respiratory distress.  His family was struggling- because he had been so good the day before, they worried that perhaps they had “given up on him” too soon.

So palliative medicine was called fairly urgently to meet with Mr K’s family(we had not been involved with his care prior to this time).

During our somewhat expedited discussion (as I really wanted to get some morphine into Mr K to get him comfortable, but couldn’t do that if they changed course and wanted to resume full treatment), I helped them remember all the factors contributing to Mr K’s overall poor prognosis- none of which had changed.

And I helped them understand that what they had witnessed the day before, that brief period of improvement, was not entirely unexpected.  Because they had been caught off guard by how well he had done initially, our friend: HOPE had crept back into their thoughts.  But his rapid decline, and impending death- was sadly, the expected ultimate outcome.  After our discussion- they were once again comfortable with their decision to shift to comfort focused care and they understood Mr K was nearing the end of his life.

The low dose morphine infusion was started which provided symptom relief.  His family sat at his bedside and reminisced, thankful he was comfortable.

But in my haste, I had missed something during my review of Mr K’s chart.

It turns out, that during the night, when Mr K became more lethargic, the neurologist had been contacted and ordered a stat head CT scan (likely he was not aware that the patient had been shifted to comfort care).  And soon after I had left them, this neurologist came by to discuss the results.  He delivered what he thought was ‘good news’- that Mr K’s head CT showed no new issues, and he told them that with rehab he could potentially get back to his prehospital baseline.  He was surprised and a bit dismayed to find Mr K on a morphine drip.  Then he left.

?!?!?!?!?

That interaction with the neurologist, initially threw Mr K’s family for a loop.  For a moment, they began to once again entertain the thought that they had made the wrong decision- but when they looked at Mr K, they remembered our prior conversation.  They knew the reason for Mr K’s unconsciousness was not due to any potential isolated ‘brain issue’, but was due to his multiple co-morbidities and his now even more damaged heart.  Mr K was dying.   And they knew they had chosen the correct treatment path.

Because sometimes providers can have the same tunnel vision as our patients and families.  It gets back to my posts about the limitations of using problem lists and systems approaches to thinking about patient care.  Providers can forget that just because the organ system they specialize in is doing ok, there are still a lot of other issues that contribute to a patient’s overall condition.  It explains why two patients with similar problems often have very different trajectories and prognoses.

This can be challenging for patients and families to understand.

And apparently for providers as well.