Her husband wasn't ready: Discussions about the end of life

Dr. Jeffrey Schnipper's story:

I see people die in horrible ways. It doesn't need to be that way! In 2011, it takes a lot of work to have a good death. The default is to not have one.

A few years ago, an elderly woman with a bad case of dementia came to our hospital for a cardiac problem. She couldn't verbalize what she wanted regarding her healthcare wishes. Her husband was not ready to let her go. He was her healthcare proxy. He and I met probably for an hour, every day, for a week. We went through the stages of grief together. By the end, he was willing to let her go.

She had a good death.

As a hospitalist, I view these discussions as a really important part of my job; so do other hospitalists. I sometimes get the chance to get the whole family together for long periods of time, which primary care providers can rarely do.

Residents tend to be very concrete about these discussions, asking, "Do you want chest compressions? Pressors? Dialysis?" And so forth. But that's not what the discussions should really be about. It should be more like, "Is your goal to get a cure? To get relief of symptoms? To be as functional as possible? To be kept alive at all costs? Would you like to die at home? What’s important to you? If you were no longer able to do [fill in the blank], would you want to be kept alive?"

Dr. Schnipper's advice: The earlier you can have these discussions, the better, so you'll have a reservoir to draw from. First, talk with your healthcare proxy, after you've chosen one, then with your primary care provider. Then, there are forms to fill out, living wills, healthcare proxies, and so on, as appropriate for the state you live in.

Read my father's end of life story.

Thanks to Dr. Schnipper for our interview of March 16.

Five minutes of education: Physician-patient communication upon hospital discharge

From Dr. Jeffrey Schnipper's research:

A patient was admitted for worsening shortness of breath and weakness. Evaluation showed ischemic heart disease [reduced blood supply to the heart], which was managed medically by changing her blood pressure regimen from metoprolol tartrate (50 milligrams, twice a day) to metoprolol succinate (extended release, 100 milligrams, once a day), lisinopril, and isosorbide mononitrate. She came to her nurse practitioner eight days after discharge for a blood pressure check, complaining that she’d been experiencing three days of scalp tingling [paresthesias] and headache; her blood pressure was markedly higher. On questioning, she reported not taking the long-acting metoprolol prescribed at discharge, because of a misunderstanding. She was brought to the Emergency Department, where she was treated, observed for several hours, and discharged home.

This was due to a discrepancy after discharge; she had stopped her short-acting drug and did not realize she needed to start the longer-acting one.

Such misunderstandings are common, partly because changes in medications are made so frequently. Upon an inpatient’s discharge from the hospital, doctors change 40% of the medications the patient has been taking, on average. “Five minutes of education of the patient and having them ‘teach-back’ what they have learned could eliminate the need for an E.R. visit later,” Dr. Schnipper says.

Advice to patients leaving the hospital:

Ask these three questions:

1.What changes should I make to the meds I’ve been taking?

2. Why are these changes needed?

3. What do I need to watch out for?

To ensure you’ve heard the answers correctly, repeat the answers back to the nurse or doctor.

Thanks to Dr. Schnipper, whose article appeared in the March 13, 2006 issue of the Archives of Internal Medicine.

She'd said Yes: Adverse drug events from a desire to please the doctor

Dr. Jeffrey Schnipper's story:
A Spanish-speaking woman came in to our hospital with very high blood pressure. She was on six different medications for it, she said, so we put her on a regimen of medications that was close to that, and that bottomed out her blood pressure! (I see something like that at least once a year.) This must have been the first time her body was actually seeing all those meds. I'd asked her in my Spanish – I'm pretty fluent – and she'd said Yes, she had really been taking all of them. I asked our hospital pharmacist to contact her community pharmacy, at Walgreen's in town, and we realized that one of the meds, she hadn't been taking for two months. Another one, she hadn't been taking for four months. A third medication, she was taking about two-thirds of the time (in other words, she was filling a 30-day prescription on average every 45 days). One medication prescription had never been filled at all. The two most costly medications, she HAD been taking faithfully. When we asked her again about her medications, showing her what we now knew, she admitted that she couldn't always afford her medications, so didn't fill all the prescriptions on time. She admitted to occasionally forgetting to take them. She also admitted that she didn't really know which medications were for her blood pressure. Each time she had gone back to her primary care provider with poorly controlled high blood pressure, her doctor had added another medication to her regimen.

She really needed TWO medications, IF she'd actually take them. So we backed off to two or three, choosing once a day, relatively inexpensive medications, which controlled her blood pressure really well. We also gave her a pill box and a refill reminder calendar to help her remember to take her medications and refill her prescriptions on time.

Advice: Tell your doctors the truth; don't tell them what you think they want to hear. If you have a problem with drugs being too costly, having side effects, occasionally missing doses, or you can't get to the pharmacy, tell them, and hopefully they can work out something that suits you better.

Read another story on a patient’s non-compliance.

Thanks to Dr. Jeffrey Schnipper for the source interview.