Fast Facts as a Guide for an Intern *

Dear Dr. Marks,

I just wanted to thank you for taking the time to give us Medical College of Wisconsin medical students a taste of palliative care and how it should be done during our third year.

I'm now in Cincinnati as a Med-Peds intern. I went from newborn nursery to the VA wards. I was covering the medicine service at the VA last night. I was called to see man with a history of myocardial infarction, who showered emboli, had a cold foot, altered mental status, terrible kidney failure, and was presumed to be septic. My signout showed he already had DNR/DNI orders. His family members were concerned about his being too sedated on an increased dose of morphine and newly added lorazepam although the nurses who called me felt as if they had finally gotten him comfortable. Going in, I knew little of what the other team had talked about with the family. As soon as I got the call, I Google'd MCW Palliative Care, not even knowing about the couple hundred education topics (Fast Facts) online at www.eperc.mcw.edu. I printed out the handout on telling a family what to expect in the final days. I knew most of what was on it, but I haven't done a lot of this as the primary person to discuss such things. So I looked it over and used it to guide my conversation. I found out that the family wasn't told anything about a timeline, though our combined teams were signing out every night saying, “We don't think he'll make it through the night.”

I explained to the family how their loved one would become less social, less aware, less hungry and thirsty (as they were trying to feed him and almost caused him to aspirate by forcing nectar in his mouth), and how his irregular respirations were normal for the dying process. We talked about the “death rattle” without using the term, though a family member already knew of the term and brought it up. Then, I gave them a timeline of a few days to a week or two at best, stating that I hoped I was wrong and that things could go much quicker or slower. I saw a huge sigh of relief and tears. They seemed to know it already. I felt like I had betrayed the primary team who hadn't given them that information, but also that I liberated a family who ultimately felt better. It seemed like the right thing to do as a doctor responding in the evening. As I left the room, we opted to attempt to decrease the newly added lorazepam, but made a strict agreement that if the patient was uncomfortable or agitated that we would add it back. I discussed how his years of dementia set their expectations up for a gradual decline but that in the final days to weeks of life, the slope very quickly steepens (I actually drew the graph I remembered from a medical school lecture). When I left, I told the family that they were his best medicine in his final days of life, and that we would simply be supporting their love with things to keep him comfortable and peaceful.

In the morning, I told the entire team about the MCW website. We seem to do things wrong because we don't know or we're uncomfortable. As interns, it's often the first time to do this ourselves. This time, I felt as if our collective team's ability to overcome the discomfort about telling the truth allowed the patient and his family to receive optimal care.

I only got one day on palliative care my third year of medical school, but that combined with the few lectures you gave to us really made a difference for me. So thank you!