American College of Physicians: Internal Medicine — Doctors for Adults ®

 
Advertisement
Friday, February 26, 2016

More than a notion

“She needs a nursing home,” someone said.

It was all matter of fact; the way such things are always mentioned on rounds with those frail elders who've slipped into the cognitive abyss. And I didn't know all the details. I mean, not enough to go arguing and pushing back on a plan that had been rolling forward for this hospitalized patient for the last week. So I responded with a simple word. “Why?”

“Dementia,” I heard them say in response. “Like, she's delirious 1 minute and then sort of inappropriate the next. It's weird. And honestly, it's mild but the problem is that she lives alone and doesn't really have anyone to help.”

“Why is she delirious?”

“Part of it is adherence to what she needs for her health. The other part, we think, is some underlying dementia. She does have someone to make decisions for her, though. Even though they can't really take care of her like we'd like.”

“No one around to see about her?”

“Well. No family that can give her what she needs. So we're pursuing nursing home placement but it's drama since she's majorly pushing back on it.”

“Dang. So she's aware enough to let you know she's not feeling that plan, huh?”

“Yeah. We just want to safely discharge her, Dr. M. So her durable power of attorney will have to sign her in against what will she has remaining.”

Eek.

Now that? That punched me in the gut and made me gasp a bit. “What will she has remaining” felt like we were playground bullies. Something about that grabbed me hard and said, “Pay attention. Go and talk to her. Think.”

Yeah.

Oh, and let me be clear: The team that was caring for this patient before was thoughtful and empathic. I know I had the luxury of being the Monday morning quarterback. The delirium portion was mostly resolved so I was looking at her through fresh lenses. Fresh enough to feel unsure about sending her to a nursing home.

Yeah.

And so. When we went in there, I listened to her speaking. This woman was older than my mother and stated proudly that she was a “Grady baby,” meaning she'd been born in this very hospital. That always resonates differently with me when I hear it from my Grady elders. In a city of transplants, the true-blue natives enamor me. She was true-blue.

Yes indeed.

And so. Admittedly, there isn't some really elaborate story that follows. I'd imagine the preamble of it all serves as a bit of a spoiler alert that she was, indeed, as sharp as the proverbial tack. And while I can't say that there weren't a few wrinkles in the fabric of her cognition, I can say that none of it was substantial enough to rip her away from the place she'd called home for the last 50 years.

Nope.

And that? That's the thing. That is the piece I put my kickstand on when thinking of her, discussing her and laying out plans with my team. This notion of uprooting people with very, very deep roots and recognizing that it's a big fucking deal.

Pardon the f-bomb.

In 2006, Harry and I had a young toddler, Isaiah, and were expecting our second child, Zachary. Harry, who has a background in real estate investment, had found this amazing home in a wonderful in-town Atlanta neighborhood, literally walking distance from my employer, Emory University. The schools in the area had great reputations and the entire environment was everything we'd dreamed of having. It certainly had some “fixer upper” necessities, but that didn't deter my husband at all. And his faith in the potential this house had was enough to get me on board.

Yep.

The home we were in at the time was lovely, for sure. That said, it was significantly further from all that we do both professionally and personally. Getting closer in would be game changing for our family. And no, we didn't need more space or anything. But this? This house was uniquely special. An opportunity just presented itself and, even better, involved my better half utilizing the skills that he'd been fine tuning for the last several years, negotiation and renovation. We didn't look back.

No one knows what the future holds, economically or otherwise. But barring any major changes, we came into that home—now our current home—believing that, God willing, we'd grow old there. I imagine myself slowing down and easing out to that same mailbox someday. Asking Harry if he fed the dog or picked up eggs or even if he wants a cup of herbal tea. And us sitting in our sunroom where the kids watch television now, shaking the hand of some young woman that one of our boys desires to marry. Then later, holding the hand of the grandchild or grandchildren that come from that union, walking through this very neighborhood to do the things that I'd been doing since I was a pregnant thirty-something.

Yeah.

So after that, I picture my mind getting foggy. Not full on foggy, but foggy enough to cause some people to do a double take. Still okay enough to take a shower and make some grits and sweep the porch and feed the dog. Fine enough to wave at the mailman and grab the bills and even get on line and pay them one mouse click at a time. But maybe just off some. Not able to remember which Bush or which Clinton is president or even how to stay on track with every day conversation. Then, I pray, that there is someone who is ready to step in and see about me, you know? To be a go between in the gap of what I can still do but the fog of what I can't.

But.

If, for some reason, that person or those people aren't readily presenting themselves, I think about someone having me in a cold, sterile hospital bed that some 911 call sent me over to on a whim because I'd fallen and couldn't get up. And then I think that, kind of like when people were put on ships and taken to the western world against their will, it must be awful to suddenly be told that you are never, ever going back to live at what has become the only home you really, truly know. Especially if my wits were still about me enough to feel that loss.

So yeah. I think of that and hope like hell that my doctor or doctors or nurse or nurses or social worker or social workers come busting in that room with their hands all splayed out screaming to everyone to WAIT, WAIT, WAIT and THINK, THINK, THINK before just signing that form to send me off and away from the home I spent my whole life building. I want them to look hard, go find someone, anyone or some kind of resource to help me. Or at least try, man. At least fucking try.

Because 30 years from now, if you take me up out of my house without warning, I won't want to go either. And I swear on my sister's life that I will fight you tooth and nail with what will I have remaining. Yes. What will I have remaining. Damn right I will.

My patient said she wanted to go home. Her insight wasn't poor and, as it turns out, there are some people around who could see about her. She was a bit forgetful and tangential but she still knew that Cam Newton was going to the Super Bowl and that he was a hometown hero, straight out of southwest Atlanta where she'd lived her entire life. And she wanted to be home to watch that game on her own damn couch where she could clap her leathery hands and drink a light beer.

And you know what? If I have any say in the matter—and I do—that's exactly what she's going to do.

Hell yeah.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

Labels: , , , , , , ,

0 Comments:

Post a Comment

Subscribe to Post Comments [Atom]

<< Home

This is a printer-friendly version of this page

Print this page  |  Close the preview

Advertisement

Share

 

Contact ACP Internist

Send comments to ACP Internist staff at acpinternist@acponline.org.

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

Powered by Blogger

RSS feed