Prescribing hope

December 17, 2010

How would you react if your doctor told you that you have 6 months to live?

Ted Nolin (all names have been changed) felt this way when he was told that his days were numbered. At age 70, heart failure was diagnosed. Ted had suffered from hypertension and diabetes, but when he was admitted a third time in severe pulmonary edema, gasping for breath, he thought that his worst fears were coming true. And his cardiologist, Dr. Hamby, wasn't very encouraging.

"Your husband has severe recurrent heart failure and probably has about 6 months to live," he told Mrs. Nolin. She was in tears. When the news was communicated to Ted, he was sad but stoic.

When Ted was admitted to the hospital for the fourth time, I happened to be on call for cardiology. The primary care physician called me and said, "Dr. Nathan, can you take care of this patient? He has dilated cardiomyopathy and recurrent heart failure, and Dr. Hamby thinks it is end stage and that he probably has only 6 more months. The patient and family know this. And Dr. Hamby is not coming to this hospital that often."

I knew Dr. Hamby still came to the hospital to take care of his private patients there. Thus, it appeared as if he had given up on Ted. Initially, I felt uncomfortable accepting the care of a dying patient just because his own cardiologist had given up on him.

"What do you want me to do? If his condition is end stage and everything has been done already, what more can I do, except give comfort measures?" I politely asked the primary care physician. Finally, I accepted the patient and got ready to give some palliative care.

A CHANGE OF HEART

It is always my policy when I take over a patient's care from another physician to take a fresh history and review all aspects of the care to get a true insight into his or her illness and see whether I can do anything more for the patient or find something that had been overlooked. I want to learn the facts first-hand. All of us have busy schedules, and sometimes we just don't have enough time to sit down with the family and go over every aspect of the disease management, despite our best efforts.

In reviewing the history, clinical data, and all the tests, it was apparent that the patient was indeed in end-stage heart failure. His work-up had revealed that he had developed severe nonischemic dilated cardiomyopathy with an ejection fraction barely over 10% (normal over 55%), no doubt contributed in part by his diabetes, moderate hypertension, and some alcohol usage. He had been prescribed the standard drugs such as digoxin, diuretics, and vasodilators; however, the use of those drugs wasn't enough to prevent these recurrent admissions. Cardiac transplantation was considered, but Ted was too old for such exotic therapy.

Now that his care had been transferred to me, I decided to do the best I could to alleviate his suffering. When I saw him first in the emergency room, he was almost frozen with terror and had difficulty breathing, coupled with a sense of impending doom. I quickly got him out of his pulmonary edema. Once his condition was stable, I sat down with him and his wife to offer some counseling.

First, I discussed his diet, explaining how he could live without much salt, and I enforced some fluid restriction. "Only about 6 glasses of fluid total," I warned him.

"And one more thing," I added. "You can't simply sit at home and watch TV, waiting for death to come and grab you. Nobody in the world can make any predictions. But maybe we can beat death at its own game. What do you say?"

He must have thought that however provocative the idea may be, it was still a mostly hypothetical concept.

"How long one lives or when one is likely to die is a guessing game, and every individual is different. We must give it all we have before accepting defeat," I tried to encourage him.

Suddenly, his ears perked up. He became more attentive; there was a twinkle in his eyes now that I had never noticed before.

"You mean I have a chance?" he asked.

"Of course. Nothing is written in stone here. Together, we can stretch this heart to work a few more months or even years. Count your blessings, Ted. At least you don't have a rapidly spreading cancer."

The look on his face told me that he had changed from a timid man to an intrepid soldier ready to fight for his life.

"That's the spirit! Let's give it our best shot," I reassured him, knowing well that this journey would be difficult.