What do you do when you disagree medically on matters on life and death?

“This was published first in the Washington Post electronically on 7/29/2017 and will come out in print this Tuesday.  Click here for the link.  The comments so far in the paper have overall been quite emotional and angry in their response.  I am happy to discuss in more detail here on the blog and welcome any input or thoughts.  But the responses in the Washington Post highlight to me why we need to not only have more questions with our families on issues of end of life but to have more depth to them as well.”

The dilemma for the critical care team was not uncommon. An elderly patient in the midst of a life threatening illness and in severe pain, not understanding the critical nature of their current situation. A decision needing to be made about how aggressive to be. A doctor trying to convince the patient to pursue a rational approach, one based on understanding the limits and capabilities of life supporting interventions. This situation plays out in ERs and ICUs across the country hundreds of times a day. But two key factors made this situation unique. First, this elderly patient struggling to breathe, battling low blood pressure and in a tremendous pain was my wife’s grandfather. Second, the doctor recommending aggressive life supporting measures, contrary to the limits set by his advanced directives, was me.

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Will The Adults In The Room Please Stand Up

Uncertainty.  In particular, diagnostic uncertainty, would keep me awake at night, early in my career as a freshly minted critical care doctor.  Patients who deteriorated without explanation or haziness on CT Scans without an identified cause, fanned the flames of my insecurity. The scenarios would leave me edgy and uncomfortable impacting my life outside the boundaries of work. Like most doctors, over the years I learned to co-exist with this uncertainty.  Human sickness and disease can be challenging mysteries.

Recently, a new kind of uneasiness has invaded my world causing all sorts of havoc. With the politicization of health care reform and attempts at repeal and replace Obamacare, uncertainty is rearing its head with a vengeance. Twitter and Facebook give minute by minute updates on which senators are a “yes” or “no” and where public opinion currently lies. The evening television roundup details rumors that have leaked from behind closed door meetings. The background noise of it all is deafening. Most discussions are focused on the future impact potential budget cuts or regulation changes. But the uncertainty created by our polarized and tribal politics on any path forward for health care reform is having a real impact now. Every hour of every day, both in the hospital and in my office where I interact with my patients.

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Sleepless Nights

You were closer to one year of age than two. Our family just three. Between surviving a combined internal medicine and pediatrics internship for me and navigating your young world for your mom, our days were challenging. But the nights. Those endless nights. As the sun would set on the cumulative fatigue of our day, the tension would grow and start to take hold. The rising dread would join our evening journey. Sleep, for you, was never easy. If and when it would come, its hold on you was more often brief and brittle. The crib lay empty and your room stood quiet, having been given up months ago. We entered nights with one goal in mind. Survive until the morning.

That night was different. The reasons escape me; exhaustion in your mother’s eyes or the frustration in mine. But that night I was determined to create a night of sleep for your mom. I pushed her out of our bedroom door, leaving just you and me behind.

You ran to the door, chasing after her. I grabbed you. Picked you up without looking you in the eye. I carried you to the far side of the bed and lay you down, tucking you under the covers. Almost before I could get to my side of the bed, you bolted up and slid off. Racing back to the door, hoping to get through and back to the comfort of your mother’s embrace. And thus it started. I rolled out on my side, intercepting you. I picked you up without looking you in the eye. I carried you to the far side of the bed and lay you down, tucking you in under the covers. Within seconds, you were sliding out of the bed. Repeating this dance. Again. And again. And again. With each repeated attempt, your determination and frustration grew. The cries louder and the screams stronger. I lost track of the number of times you bolted for that door, blurred by the tears streaming down my face.

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10 Tips For New Interns For Surviving and Thriving in the Intensive Care Unit

July is just around the corner. For hospitals it’s a dynamic time. A changing of the guard. Graduating residents moving on and new interns, fresh out of medical school with their clean and crisp long white coats, moving in. Out with the old, in with the new. The ICU rotation for medicine residents and medical students is stressful under the best of circumstances but always an additional challenge early in July. I remember as a resident, trying to glean from my peers who had already completed their ICU rotation, picking their brains for tips and tricks on how to survive and succeed. But often what we are looking for is not what we need the most. Acid base disorders and ventilator management seemed so daunting. But in hindsight, learning how to manage and treat specific diseases and conditions was not the hard part. Learning how to survive, mentally and physically, the rigors of the ICU and growing as a physician were much bigger challenges. Read more