Wednesday, August 6, 2014

Potpourri from clinical work VII

by: Alex Smith, @alexsmithMD

The following are some reflections from being on service recently.  Not enough time to develop these into full posts.  If these issues tickle you, please respond in the comments!  To see previous potpourri's from clinical work follow the links to I, II, III, IV, V, and VI.
  1. David Reuben wrote a terrific perspective describing "The Hospital Dependent Patient."  These are patients who, usually elderly, who have chronic illness exacerbations that frequently land them in the hospital.  In the hospital they have a high quality of life, when surrounded by nurses and treatments that can only be delivered in the hospital.  I cared for one such patient.  He had frequent episodes of low blood pressure following dialysis, landing in him in the hospital over and over again.  He also had early dementia.  He could remember enough to think that he should be in dialysis most days, even when it wasn't his usual day.  Normally tired and sleepy, in the dialysis unit of our hospital, he came alive, talking animatedly with his "community" of care providers.  In goals of care discussions, this patient was clear that he enjoyed his quality of life and had no issues with returning repeatedly to the hospital for care.  As Dr. Reuben points out in his perspective, hospital-dependent patients are a product of our medical progress.  We have yet to grapple as a society with how to provide care for this increasing population of patients.  Nor have we addressed in a mature way the ethical issues around setting limits - if any - around what care our system should support and can afford for Hospital Dependent Patients.
  2. Cough is a tough symptom to treat sometimes.  I had a patients with cough and dyspnea on exertion due to idiopathic pulmonary fibrosis.  He did not believe that the opioids were helping him.  The pulmonary team suggested gabapentin, but my read of the literature is there is only case report level evidence.  The patient died before we could try alternatives.  What have you used for chronic opioid refractory cough?
  3. We had a patient who we communicated with just fine in his room.  No issues.  Then we had a family meeting.  Big room, lots of providers, including the medical team and 3 consulting teams.  We get about 1/3 of the way into the meeting and the patient says, "I can't hear what your saying."  Turns out he had hearing loss and we had no idea!  Brings home to me the importance of this issue.  In the room, alone, with the door closed, and 3 feet away from the patient's head, communication may be just fine.  But in a large family meeting, you may find a completely different experience.  Should we be screening for hearing loss in all of our patients over the age of, say, 75?  How should we screen?  Do you have ready access to pocket talkers for patients who have hearing loss?
  4. We cared for a man who experienced a hip fracture in the nursing home the other day.  His geriatrician care providers and surrogate decided that, as his pain needs were minimal, and he was in his 90s with dementia, they would not persue surgery.  Several months later we saw him and he was able to walk short distances to the bathroom, but did not try to venture out to the front desk as he did before the fracture.  Hindsight is 20/20, but it seems they made the right choice.  Other people's experience with non-operative managment of hip fracture?  Eric wrote about outcomes of hip fracture among nursing home residents last month.
  5. One patient requested that we start each mornings visit to his room with a joke.  What fun!  I told him some from my 6 year old son, like:
    1. "What's your favorite jam?" "Peach" "What's your least favorite jam?" "Grape" "But what about a traffic jam?"
    2. "Why is a nose not 12 inches long?" "Because then it would be a foot"
    3. This one is from Darth Vader's twitter feed (you follow him, right?) "How did Luke Skywalker stub his toe on the planet Endor?" "Ewoked into a tree."
    4. This one is from our team psychologist, "How do you make seven an even number?" "Take out the S"

8 comments:

Maggie said...

3. Several patients I've seen recently have been advised - by primary care physicians, sometimes, and also by admissions desk personnel - to leave their hearing aids at home! This is apparently because hearing aids are tiny and expensive, and may often become lost in bedding changes especially if the patient doesn't remove and store them before dozing off. But really -- patients need their hearing aids, glasses, false teeth, canes, and other assistive devices. Hospitals should be working toward supporting their use for inpatients, not telling them to leave them home.

Alex Smith said...

Wow Maggie! I have had patients lose hearing aids in the hospital. But the alternative - not being able to communicate well when sick enough to be hospitalized - is worse! Really, hearing aid costs should be subsidized more heavily (if they are subsidized at all).

George Handzo said...

On #1, the observation that the pt comes alive in the hospital with his "community" of care providers strongly suggests he has no community out of the hospital. Research in spiritual needs has pretty consistently found community/connectedness as a prominent need. So I would be trying to connect him to some community that has meaning for him. No silver bullet of course but may be a big part of the pts hospital dependence.

Alex Smith said...

Hi George - great comment, absolutely agree.

Rachel Wynn said...

I am a speech-language pathologist and I use jokes in therapy all the time. Memory: It's something fun for a patient to remember to tell a nurse or other staff member. Motor Speech/Vocal Volume: Speak loudly and clearly enough for your listener. We can also target prosody (rhythm of speech). Language: interpretation of figurative language.

Two of my favorite jokes:
Can you eat strawberries on an empty stomach? Yes, but it's better to eat them on a plate.
Do you know why I like chicken? Be-cause (that sounds like a chicken's "bawk").

Regarding the hearing loss and hearing aids. I have found it very common for my patients to be missing hearing aids or have such significant wax buildup that they hearing aids aren't working. I have also found that hearing loss can be influenced by mild cognitive impairment which can make communicating with distractions or multiple communication partners difficult. We should also be screening for MCI.

Alex Smith said...

Hi Rachel, thank you for your comment. I was tempted to try and use the "introduction with a joke" strategy with other patients, but was unsure how to do so. More of an opportunity and justification in speech pathology!

Completely agree- hearing loss + mild cognitive impairment makes for challenging discussions.

Helen Chen, MD said...

Thanks, Alex. The concept of the 'hospital dependent patient' is one we live with every day in the LTACH world. It is often very difficult to have a "mature discussion" because time and again, patients and families have seen that a return to inpatient acute results in some improvement. And, repeated returns, while perhaps 'futile' in the metaphysical sense, actually aren't futile in that they may result in an aggregate of many months of more time, which can be desirable for individual families/patients. Whether we can "afford" this from a societal perspective, is really the elephant in the room.

Re: whether to leave your hearing aids at home, I remain conflicted. I know of cases where hearing impaired patients were falsely labeled as "difficult" or "delirious" when really they just couldn't hear. However, the ability of a family to scrape together another $5-10K or more to replace a set of aids that has gone missing during a transition (and no you can't always get the hospital, the SNF, or the ambulance company to help defray the cost), is also a challenging one.

Alex Smith said...

Thanks Helen, I appreciate your thoughts. The leave the hearing aids at home question is concerning, from all angles. If they do leave them at home, then it seems the ambulance, hospital, and SNF should go out of its way to identify such patients and provide a pocket talker at a minimum.