A letter to the patient’s wife on the fourth floor

November 29, 2008 at 10:47 pm (Clinical rotations)

Dear Mrs. Canseco,

You and your husband have had a long, fulfilling life together. Ever since your marriage over 50 years ago, you have stood by his side through good and bad times. And when he was diagnosed with end-stage lung cancer this year, you were there ready to support him to his last breath. However, there comes a point when devotion gives way to fanaticism—and you cross that line a few weeks ago.

When your 75-year-old husband was admitted to the hospital two months ago in respiratory failure, the admitting physician was not being cruel when he inquired about Do Not Resuscitate status. He had nothing personally against you or your husband when he brought up the idea of seeking Hospice care.

You wouldn’t hear any of it. You demanded that your husband be placed in the intensive care unit and be given round-the-clock supervision by nurses and physicians. When I spend five minutes with your husband every morning pre-rounding, followed by another 30 minutes telling you that nothing has changed in the past 24 hours, stop accusing everyone on the staff of “not explaining what’s happening.” Your weekly family conferences where my attending and I sit down with you, your three children, your brother, and two of his kids are really getting to be a drain on our time. I just don’t know how many other ways I can tell you that after being in a coma and on a ventilator for the past two months, your husband really doesn’t have a shot in hell of living through this. You have refused pain medications, saying that we are, “Killing your husband.” You have declined a Hospice evaluation, stating that, “We are turning our backs on your husband.” When we brought in a pulmonologist to reevaluate the situation, only to have her agree with us, you accused her of, “Not knowing your husband.”

But expertise be damned. Your daughter, the massage therapist who has had extensive training in medicine, told you that she believes your husband will make it off the ventilator without any problems if we just wait a little longer.

You’ve treated our hospital like it’s a hotel, having moved in and spent 61 consecutive nights sleeping in your husband’s room. You have refused to leave the room under any circumstances, claiming that bad things would happen to your husband if you walked away. You have demanded that the hospital provide you with meals from the cafeteria three times a day. You have demanded that nurses be forever present in your husband’s room so that they can respond to your every beck and call. You have neglected that these hard-working nurses have four—sometimes five—extra patients who are also very sick and must be seen. I wish I could just put a white coat on a mannequin and place it in your room to try to give you some kind of solace. He could have an outstretched arm to hold your hand with an audio tape on continuous replay saying, “I am here for you.” Because in the end, that’s all that I can offer you at this point.

And then there’s the issue of the money. Don’t act like it doesn’t exist. The combined hospital bill from your stay so far is going to run well over $200,000. But you have never cared how these services are going to be paid. You proudly flaunt that you have no insurance and since you’re not an American citizen, you are ineligible from Medicare. Neither you nor your husband own any property. When it comes right down to it, we’re all really working for you for free.

You have shown us that you know more about the pathophysiology of a coma than any physician ever could. You have taught us that living on a ventilator is better than dying with dignity. You have pointed out that our nurses are incredibly mean and lazy for not dropping everything they’re doing in another patient’s room to come see your husband, whose condition has not changed in two months. Thank you for giving me the opportunity to learn by having your husband as a patient. Thank you for teaching me that everything my attendings tell me is wrong, that medical care is free, and that nurses don’t care about people in a hospital.

Sincerely,
Half M.D.

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12 Comments

  1. Scott said,

    When will this ever end…

  2. Chris said,

    What’s your feeling on the proposal that insurance companies accept anyone who applies for coverage provided that everyone in America is required to obtain coverage? Some Scandinavian countries have been doing this for a few years and even Blue Cross Blue Shield recently recommended it for the Obama administration.

  3. halfmd said,

    I think that such a proposal would force many companies into bankruptcy. Insurance companies exist for the sole reason of making money. They aren’t there to provide health care to patients. They aren’t there because they care about a person’s physical and mental well-being. They don’t exist with the goal of connecting the sick to healers. Their only reason for existence is to make money. Forcing them to accept clients with pre-existing medical conditions who make very little money is a losing proposal that seems eerily similar to the EMTALA rules that have forced so many hospitals to abandon their emergency departments.

  4. thehillbillyhealer said,

    I agree. The only solution to our problem is a one payer system. If the American people aren’t ready for it then its time the smart folks force it on them. “Socialized Education” has turned out pretty well. So has “Socialized transportation systems” (i.e. interstates). I also like the “Socialized defense system”. When it comes to services that should be rights for all Americans, education, security, the ability to conduct business, HEALTH CARE, big business is not the way to go. This whole situation is averted with a one payer system.

  5. JT said,

    Competition minus constricting regulations drives prices down and quality up. Self-interest can be harnessed for the good of others, that’s what makes nations great. Name one industry that’s currently operating more efficiently, sending a better product to the end-user/consumer, and operated by a single provider or tax-payer funded government program? When person C spends person A’s money on person B, disaster strikes. No interaction occurs between the very two people most knowledgeable about the situation.

  6. thehillbillyhealer said,

    So your saying you don’t believe a one payer system will be able to handle the insurance side? A one payers system will not affect the quality of health care because there is not only one health care provider, or one health care system. There is one INSURANCE system. So if competition is to raise any kind of product it would be the insurance not the health care. If you want to make a relevant argument against a socialized medicine a feeble economic/competition argument falls way short. Why do you think the AMA is in favor of socialized medicine? They WILL be ASSURED of getting paid.

  7. Med Student said,

    No pain meds????!!! Why hasn’t this case been handed over to the ethics committee? Because she is clearly an illegitimate surrogate, a normal one, who actually cares about whether the man is in agony or not, should be appointed on his behalf.

  8. Scrub Notes said,

    Hm, a sad story. At some point, I think most hospitals have an ethics committee you can consult about such situations in order to mediate such situations. At least, I would hope your hospital does.

    Also, while not a big HIPAA fan, I hope you made up the lady’s last name…. just a thought.

  9. halfmd said,

    Yes, I did make up the name.

    And if you think that a hospital’s ethics committee holds any kind of authority over crazy family members, your optimism is going to bite you down the road. Some people can never be reasoned with.

  10. ArkieRN said,

    *sigh*

  11. Air Force Dave said,

    Good read. Thanks for this interesting article.

    I went through these same situations in St Louis during residency many times. I wish that we could have reasoned with people more often regarding hospice and withdrawal of care, but for many people there is a suspicion toward physicians.
    Others seem to believe that consenting to hospice or withdrawal of care is nothing more than killing their own family member. At times 7/8 family members would consent to withdrawal and the spouse would reject it.

    For these really tough cases, trying to understand what their religious and ethical dilemmas are may help you find someone who can get through to them.

  12. ilaria said,

    Well, thank goodness I’m in medicine a completely different context – and in a context where everything we hear is completely incorrect, as I am beginning to see. We were always taught of how cruel and unfair american healthcare is – that if you don-t have money you just “stay sick” and that only the rich actually get the care that they deserve – damn private health care. What they never tell us is how situations such as this come about and how they are dealt with.

    Here in Italy we don’t have these problems. You know why? Because what you just described, is our TYPICAL patient. Andour typical patient’s pain in the ass wife. Here health care is FREE (yes, read it twice now, free). You not only don’t pay for the services but THE REST OF THE COUNTRY PAYS! Think of endless healthcare and everyhing for not a dime. And just think of how easy it is to abuse of it all.

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