“How would you handle a 90 year-old patient in the hospital who refuses to let the nurses change her until we let her go home? She’s been sitting there in her own urine for 24 hours, and I just don’t know how to help.”
Five months into my geriatrics fellowship, I thought maybe I could handle this one. I suggested that likely she’s likely very frustrated about her declining health and her ability to care for herself. She recognizes that her independence and freedoms are slowly being taken away from her. She’s probably trying to exert control the only way she can.
The other comments from the group were very different. “More colace,” one said jokingly (from the friend who thinks that’s all I prescribe). “Oh that’s ‘failure to thrive,’ she should be conserved,” another weighed in. “I’d just put her in long-term care, there’s nothing TO do,” said another.
I realized then how much these five months had already changed me. My viewpoint had shifted, and I wasn’t seeing things the way my colleagues were anymore. I still knew the complex physiology and I still got excited about the mystery diagnosis, but now I was managing patients way more challenging than I ever had in residency. They had multiple medical problems combined with frail cognitive and functional issues, sometimes complicated by loneliness and a loss of dignity.
This was not doctoring I read about in books or learned from writing orders on the wards. This was an art of balancing the social with the emotional, the physical with the existential.
“I just wanted to brag about my glamorous life,” my hospitalist friend said jokingly about the case she presented me.
Glamorous. I looked up the meaning. One definition was “full of excitement, adventure and unusual activity.” Well, I’d have to say taking care of older adults IS very glamorous.
I’m still excited every time Mrs. S, a lively 96 year-old lady, tells me how she met her husband. (Her dementia has progressed, she doesn’t remember she has already told me this many times.) “It was 1934, and I was on a 3-day train trip from Texas to San Francisco. There were 250 military men on the train and 8 ladies. I had my pick of the litter and we had a ball,” she laughs until tears fill her eyes. We giggle until our stomachs hurt, but after a while, we decide to talk seriously about her blood pressure. It has been low lately, and the dizziness it causes may be the reason for her recent falls. Although she may need the medication for her heart failure and to prevent a future heart attack, I have the difficult decision of weighing the risks and benefits of the medication.
There are no studies to guide my clinical decision-making. (In fact, there are very few studies that include any 96 year-old patients at all). There is no review of the literature I can do to determine what the “best” answer is. Instead, I have the glamorous job really listening to what’s important to her, what gets her up in the morning, and what sacrifices or risks she is willing to take so that she can have the life that she wants.
My job is so exciting, adventurous, and unusual that I get to individualize the care I provide for every person I see. Its scary territory when there is no case like another in which to guide my decisions.
My patients’ lives are filled with amazing stories and memories. They have survived decades of experiences, with peaks of joy and valleys of suffering. They continue to have dreams and wishes. They still have many tear-filled fits of laughter left. My job IS glamorous because I get to do my best to get them there. And I’m loving every minute of it.