Expanding the paradigm of patient-centered care: patient, family and dog dynamics

October 31, 2018

2018 Physician Writing Contest runner-up

After ten years as a hospitalist, my job continues to get more and more interesting. The new horizons of patient experience present a series of ongoing challenges. A few months ago, for instance, I admitted a 93-year old female, Ms. X, with bilateral pneumonia with shortness of breath, cough, and a temperature of 101oF. The Emergency Department chest x-ray revealed bilateral extensive consolidation, and the patient was put on the appropriate treatment regimen. She started showing improvement after the fifth day of admission with reduced shortness of breath and resolution of the fever. While progress was slow, the patient and her three children remained upbeat.  Her two sons had come from out of state to help their sister, who was living in the same town as their mom and was the main caregiver.

Unfortunately, on the sixth day of admission, I was paged STAT to attend to Ms. X, who was in respiratory distress. With many thoughts crisscrossing my mind, I rushed to the aid of this elderly patient. After a couple of breathing treatments and oxygen administered via the nasal canal, she quickly stabilized. The repeat x-ray showed no change in lung status, and the pulmonologist added chest physiotherapy and Mucinex to the treatment plan. These changes helped her to improve. The next day, however, she continued to have respiratory distress, which was not resolvable. An echocardiogram to rule out congestive heart failure exacerbation was normal, and her response to IV Lasix during the crisis period was minimal. However, this respiratory distress continued, even after nine days of admission. Both the patient and the family were worried about her deteriorating health and decreased food intake. 

On the ninth day, I was called into the patient room for a talk. Ms. X looked at me and said, “Doctor B, you are a good doctor and you are trying your best. You know I am not young anymore. I have been experiencing a great deal of suffering, and I am having continual difficulty breathing. Can you let me go peacefully?”

Surprised and somewhat emotional, I looked at her to make sure she was mentally oriented and that her decision-making capacity was in intact.  Meanwhile, the daughter and two sons asked if we could talk outside. I readily agreed and took them to an empty patient room and closed the door.

Ms. X’s eldest son said, “Doc, it appears that my mom is suffering and not likely to make a full recovery, despite your continuous care. And now she has even stopped eating. How can we end this suffering?” I looked at the other two children, who were both nodding their heads in confirmation. Both said, “My mom did not want to live like this.”

By then, I had realized Ms. X was not recovering from her extensive pneumonia and that her chances of recovery were severely affected by her COPD due to passive smoking, old age, low nutrition, and her fragile body. She was extremely weak and was now refusing to eat. After careful consideration, I offered them hospice care. I explained that this is an end-of-life care process, the aim of which is to keep terminally ill patients comfortable during their final days. The family agreed for their mom to be placed in a home hospice.

After this meeting, I went to back Ms. X’s room and started my conscious conversation. I explained that she was not getting better and that her health was worsening day-by-day due to extensive pneumonia with underlying COPD. I said, “I understand that you are suffering. But you should know that there is hope. The option is to place you under the care of hospice service, which concentrates on the patient’s comfort rather than the cure.”

Ms. X was happy to hear this option. She immediately said, “Let me join the Lord.” I fully agreed with her decision and said that I would arrange for hospice care at home. The patient asked, “Can you arrange for it today?” I knew the process of arranging hospice care takes some time, and I told her it would take at least 24 hours. Ms. X’s daughter said, “Do your best, Doc. Her dog, who has been with her for ten years, has been waiting anxiously for her every day by the front door window. If she could go home today, that would make her dog happy. And perhaps my mom would be extremely happy too.”

From cure to comfort and the urge to make a dog happy

With fresh guilt at sacrificing the dog’s happiness if Ms. X did not go home that day, I swung into action without hesitation.  Bypassing the case management protocols, I called a hospice agency directly to arrange a consultation to evaluate Ms. X for home hospice placement. After a couple of hours, the agency arrived and approval was granted.  I signed all the appropriate papers, and the agency assured me that it was not a problem to arrange for home placement that day, as this patient had original Medicare.

At 6 p.m., while on my rounds, I received another phone call from the hospice agency, saying, “Dr. B, there is a problem. We cannot accept her today. But it should be possible tomorrow.” This information broke my heart. Furthermore, the agency did not know that my patient-centered care paradigm also included a loving dog, who was waiting for her owner to return home. I thought about this for a few minutes and decided that I did not want to simply give up. So, I called them back and asked, “Can you not provide hospice care in a patient’s own bed?” I requested again that she be allowed to go home that day, and then I finally told them about the pet dog who was waiting to see my patient.

This may have tugged their heartstrings as the lady from the hospice agency agreed to provide care in Ms. X’s own bed at her house. The patient was discharged that day and taken home without further delay.

This was such a joyful moment. I was so emotional about the whole patient experience scenario that I locked myself in my room and thanked my emotions for sparking my motivation to display empathy and help this patient. This in turn led to an expansion of my patient-centered care paradigm to include a beloved pet in my decision-making process. My instincts in this scenario reminded me that I was blessed to be a doctor, learning life lessons while helping the needy.

I feel that expanding the boundaries of physician’s services and going the extra mile to make a real difference in the lives of patients is not only our professional duty as doctors but also a human obligation that we owe all the people in our care. Compassion-filled care not only comforts patients but also elevates doctors’ motivation levels and enriches our people skills.

Editor’s note: Patient names were changed to preserve privacy.

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