Tucker

Sometimes a cold nose, four legs, and a wet sloppy kiss can be the best medicine. Dr. GL taught us this lesson about living. Tucker, of course, is his beloved dog. With apologies to Biblical scholars, of Faith, Hope, and Love, Love is the most important.

After many years of marriage and previous health scares, Dr. and Mrs. GL finally came to face a life-limiting disease and a conundrum of choices. They specifically requested a palliative care consultation, admittedly, with an incomplete understanding of palliative medicine. After chart review, we discussed the case with the referring intensive care physician and case management prior to the consultation. The palliative care team composed of chaplain, palliative medicine fellow, and faculty introduced ourselves and described the broad concepts of palliative care to Dr. and Mrs. GL. With their permission we assessed their understanding of the diagnosis and prognosis; more importantly, their wishes.

As is often the case with any complicated medical condition, there was no consensus on the plan of care among the intensive care medical staff, the patient, and family; indeed, there were widely divergent views regarding the manner of care, vis-à-vis, the ultimate goal. The intensive care medical team hesitated to honor the patient's request to stop aggressive diagnostics and therapeutics fearing it could indeed shorten his life. In order to reconcile these divergent professional opinions, the attending intensivist, case management social worker, and faculty of the palliative care consultative service debated the patient's condition, prognosis, and decision making capacity. Each diligently represented their perspective with genuine respect for each other in order to honor Dr. GL. We ultimately approached the patient and family with trepidation and caution under the lead of the palliative care faculty.

In our earlier discussions with the family we learned of their condominium on the ocean, love of the scenery, including an osprey nest and, of course, Tucker. We again asked him what he was hoping for. He described an overwhelming sense of hopelessness and despair to the extent that he no longer saw any point in living in his current condition (in hospital). When asked if a nice wet sloppy kiss from Tucker would give him hope, he smiled and with unconditional love radiating from him, he shared the joy of the last homecoming greeting from Tucker. He beamed with joy. His demeanor changed. He told his wife and daughter of his unconditional love for them. The focus of hope was manifest! The patient, wife, and daughter ultimately chose transition via inpatient hospice to home to be with Tucker and each other.

Fidelity is “the quality or state of being faithful” (Merriam-Webster Online, 2013). In palliative medicine, fidelity is being faithful to a patient's wishes and respecting the right to choose his or her own course. This choice, however, must be guided by genuine patient-centered communication about current clinical status, prognosis, and possible course of illness, leading to discussion of the patient's options. In regards to Dr. GL, the medical team failed to recognize the patient's true goals and was fearful of his right to accept or reject medical treatment. Review of literature has indicated a lack of awareness by physicians and medical staff regarding patient's preferences, suggesting that care is being offered that is inconsistent with a patient's goals. ¹

It is our role to elicit their goals, based on their hopes and their aspirations. We are compelled to respect these goals and hopes with fidelity. “We hope for what you hope for and we will create a plan of care to meet your goals.” It is important for all of us to remember that hope means different things to different people; and hope means different things to the same person as he or she moves through different stages of illness. ² To Dr. GL, hope came in the form of a cold nose, four legs, and a wet sloppy lick. This, of course, was the best medicine.

We all need a Tucker.