TAUREEF MOHAMMED
IT WAS as though the elderly woman was going around a revolving door: in for breathlessness, out in a few days with a diagnosis of heart failure; in for drowsiness, out with cirrhosis; in again after a fall, out with a prosthetic hip and a referral to geriatric medicine.
'What is the most important thing to you?' the geriatrician asked.
'Seeing my grandchildren.' That was it. Nothing else in the world mattered.
Finding out what matters most is an important part of assessing any sick person - especially the elderly - but it is not always straightforward.
I remember once seeing an elderly man in the emergency department shortly after midnight. He had multiple end-stage chronic diseases, lived in an assisted living facility, and was now very sick: he could barely open his eyes, mumbled incomprehensible sounds, and his vital signs were deranged.
We thought he had a bad infection, so we did a battery of tests, which included an unsuccessful spinal tap; started him on a cocktail of antibiotics; gave him intravenous fluids which eventually leaked out of his blood vessels into his lungs, causing him to require oxygen through a face mask. And when he continued to decline, we infused a medication to force his heart to beat stronger. I would be lying if I said there was not a voice in my head saying: What are you doing?
The sun rose, my shift was over, and it was time for handover to the consultant and her team. 'I probably wouldn't have done that,' the consultant said, contemplatively. 'Sometimes you need to step back and look at the big picture.'
We had tried. After a discussion with the patient's distraught relative at bedside, we had decided to go through with the tests and treatments. But the consultant was right: I did not step back enough. Maybe if I had taken the patient's relative out of the chaotic emergency room into a quiet room, probed more about who the patient was, what was important to him, what he valued in life, then maybe things would have been different.
In a study published last year in the Journal of the American Medical Association, 163 patients over the age of 65 with multiple medical conditions were asked what mattered most to them. The majority said being able to spend time with family and friends. One person - one out of 163 people - said living longer mattered the most.
The challenge in medicine, particularly geriatric medicine, is providing the appropriate care to meet these real-life goals.
The thing is we doctors spend a lot of time in a world of numbers. Mortality rates, life expectancies, vital signs, laboratory results, drug dosages swarm about in our heads during our sleep. We cannot escape the numbers; medicine is a science after all. But patients occupy a vastly different world: the real world, an unmeasurable and undefined place.
Bridging both worlds can be difficult, especially at 2 am in an emergency room.
A group of researchers at Yale University recently
