Don't Just Treat the Patient, Treat the Family

As an inpatient internist, I see on a daily basis many elderly, moribund, bed-bound, chronically inflamed, demented patients with multi-organ system insufficiency or dysfunction. They come from nursing homes or from their own home with an advance directive stating that they desire full resuscitation in the event of cardiopulmonary collapse, and there are at least three phone numbers to reach the next of kin. Within fifteen seconds of recognizing this extremely common scenario, I realize who I’m really treating - the next of kin family member, usually an adult child. I expect to get several phone calls within the next 48 hours inquiring into the status of the beloved parent or grandparent, and I must demonstrate not only reversal of the acute deterioration necessitating hospital admission, but also I must address the family member’s chief complaints, which often is of no clinical relevance, but really is an expression of disdain for the nursing home or previous providers who had cared for the patient.

In the past my first thought was: How could the primary-care provider not make this patient "no code" or at least discuss the big picture issue with the family? The big picture is of course that there’s just no hope. There’s no quality of life, just slow ugly, painful deterioration, especially when the question of feeding tubes arise. Does it matter whether hydrogel was put on that stage 3 buttock ulcer? Yes, perhaps acutely since it may be a source of sepsis but chronically it doesn’t matter. The patient is going to die. Whether during this admission or the next, I cannot predict.

But now I don’t waste time fussing about what should or could have been done to prevent useless admissions keeping the living dead alive. That’s just not professional. I focus on the family member who spends every waking hour at the bedside or on the phone calling the nursing station. I pay attention and make sure every issue they bring up is addressed. Plus I explain every clinical issue with painstaking detail, giving the impression that I know their parent so well, and that they can relax. Do I really? Well luckily for me, their parent’s body deteriorates in the similar pattern as that of most chronically ill patients with poor heart, liver, kidney, lung, or brain function.

After the establishment of optimal rapport (the best clinical skill in the game), that is when I can finally get past the academic medical stuff and focus on the really important issues - the quality of life, the code status, figuring out what the patient would want if they could make their own decisions, and usually, unless an unrelenting and annoying religious sensibility gets in the way, the family member does get the picture, and releases their own guilt (because it is always about them), and makes decisions maximizing quality of life.

Nature has its way. It leads to decay, unless you do something about it (see last week’s blog about healing). But most patients who are elderly, feeble, and severely ill in 2011 cannot do anything about it. Their generation, the baby boomers, learned about nutrition and healthy lifestyles way too late. The only things we can do for them are to maximize their mobility, providing loving home environments for them, avoid nursing homes, fill up on Vitamin D, control their cardiometabolic risk with as minimal medications as possible (substitute red yeast rice or fish for statins), and maximize mental stimulation to avoid depression and progressive dementia. And it is generally better to receive palliative care earlier rather than later.

Regardless of their endpoint, I envy this elder generation. After all, they had the opportunity to experience the 1960s!

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