Skip to main content

Nowhere Else to Be

The following story is by Jennifer Heidmann, MD, FACP. She is the Medical Director of Redwood Coast PACE in Eureka, CA, as well as a physician for Hospice of Humboldt and a hospitalist at St Joseph Hospital.

"You played with Oscar Peterson?" I said, and he looked at me for the first time. His feet hung off the end of the too short ER gurney, out of place as was the rest of him here. I fit in, white-coated, pockets weighed down with smart phones, twenty-first century pagers, getting through my review of systems and filing away his monosyllabic answers so I could finger-chat them to the electronic medical record. He is old and congestive heart failure is his ticket inside this hall, which I intuited not by his words which he held close but by his B-natriuretic peptide and plump jugular vein. Like any good musician knows, the well placed silence makes the notes played pop out and grab the listener.

I like to know what people have spent their life doing, in case I can use it against their disease. It might inform me of risk, exposures, personality. The danger in this is defining health as having a role to play. Band member, surgeon, teacher, mother is no one without air to blow their horn, steady hands and sharp mind, a class to prepare, a child in the nest. Fluorescent emergency room shines a spotlight on current frailty. Even outside the ER, in any context: too slow, not productive, and thus disabled.

What is my job? I wield elixirs to right physiologic wrongs. I take clues gathered from words and my prodding touch and produce a finished product, titled by its ICD 10 code. Everyone wants my autograph. I exist because someone else is sick or dying or breaking down little by little.

My experience is expressed in the grey hairs which assert themselves enough that I am no longer asked if I am old enough to do this job. I should have so much to say. Yet what geriatrics and hospice and hospital medicine has taught me is to sit still and be quiet. It has occurred to me that the person I sit across from is my Zen Master. The musician with CHF spoke little by choice, not prone to waste air or add to the cacophony of the emergency room. The teacher with Lewy Body Dementia had words stolen from her. She always had well-meaning sentence finishers at her side. I decided to wait, sitting on my rolling clinic chair, looking at her intelligent face. I can because I practice "don't-rush-us" medicine. Over the months she told me astounding things about loss, and I discovered she had a wicked sense of humor. The silences between my words and hers were long, the kind of focused emptiness where you forget anything else in the world exists. When she could no longer speak at all, I sang and she joined me. You are My Sunshine.

Is it possible we create disability with our definition of health and wholeness? Would dementia or a slow gait or dyspnea on exertion be as pathologic if we did not so worship keeping up? What if the ones we leave behind in our wake of productivity hold the key to the meaning of life in their trembling hand? We have created a society that cannot tolerate and is frankly terrified of infirmity and decline and death. The bills stack up, our careers demand attention, our friends have things to do. If we dare to stop and acknowledge humanity in someone who can no longer wipe their own butt, what does that say about our own rushed existence?

You, patient, are a problem for me to solve. I can reach out and control your atrial fibrillation with the force of my education. I can tell you with some certainty what kind of dementia you have. I can cure your pneumonia and let you see another day. What are your goals of care, I am trained to say. Though I prefer now simply what are your goals or what is important to you? Which is undeniably important but hard to express if you cannot talk or cannot recall what you had for breakfast this morning. In which case I want you to know that I see you. Right here and now, not what you do or who you were or who the world wishes you could still be.

The man with CHF improved, because of or perhaps despite his hospital stay. I brought in my iPad, handing it to him and pushed play. As he stared at the album cover that included his name on the screen, a tune played. He played. He turned the iPad over, wide-eyed, as if to say "what magic is this?" The magic is just this-you and I sitting here together, with nothing else in the whole world we need to do


Unknown said…
This is a beautifully written piece about the healing power of presence. Thank you.
Anonymous said…
Sadly, our society, with all of its progress, is still very intolerant of anything that appears to get in the way of its catapult to "more". This parallels medicines reliance on machines and less on eyes, ears and hands.
As a mom of a 26 year old non-verbal, profoundly delayed and medically fragile adult son and a nurse, I straddle these 2 worlds. As this beautiful piece articulates, the richness is in what happens when you slow down and be. Thank you for this.
Elisabeth said…
As a former hospice social worker, I love your use of "non-rush-medicine". Do you get organizational support for this, is it part of your hospital's philosophy, or are you an anomaly? Either way, I think you are absolutely providing an amazing honest humane service. Keep it up. You are a poet.
John said…
You are a lovely human being and I am so pleased and honored to work with you
Wassdoc said…
Wonderfully written examples of how Geriatrics (including hospice and palliative medicine) embodies person centered care. Thanks for sharing!
This is because they will now have the cover that comes from the absence of the NGC when they do things that are not supported by the best evidence available. Canadian Pharmacy

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…

Survival from severe sepsis: The infection is cured but all is not well

Severe sepsis is a syndrome marked by a severe infection that results in the failure of at least one major organ system: For example, pneumonia complicated by kidney failure. It is the most common non-cardiac cause of critical illness and is associated with a high mortality rate.

But what happens to those who survive their hospitalization for severe sepsis? An important study published in JAMA from Iwashyna and colleagues provides answers and tells us all is not well. When the patient leaves the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits.

Iwashyna examined disability and cognitive outcomes among 516 survivors of severe sepsis. These subjects were Medicare enrollees who were participants in the Health and Retirement Study. The average age of patients was 77 years.

When interviewed after discharge, most survivors were left with major new deficits in their ability to live independently. …