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Death By Stubbornness: What’s A Doctor To Do?

Over the years that I’ve worked in acute inpatient rehab centers, I have been truly vexed by a particular type of patient. Namely, the stubborn patient (usually an elderly gentleman with a military or armed forces background). I know that it’s not completely fair to generalize about personality types, but it seems that the very nature of their work has either developed in them a steely resolve, or they were attracted to their profession because they possessed the right temperament for it. Either way, when they arrive in the rehab unit after some type of acute illness or traumatic event, it is very challenging to cajole them into health. I suspect that I am failing quite miserably at it, frankly.

Nothing is more depressing for a rehab physician than to see a patient decline because they refuse to participate in activities that are bound to improve their condition. Prolonged immobility is a recipe for disaster, especially in the frail elderly. Refusal to eat and get out of bed regularly can make the difference between life and death within a matter of days as leg clots begin to form, and infectious diseases take hold of a body in a weakened state. The downward spiral of illness and debility is familiar to all physicians, but is particularly disappointing when the underlying cause appears to be patient stubbornness.

Of course, the patient may not be well enough to grasp the “big picture” consequences of their decisions. And I certainly do not pretend to understand what it feels like to be elderly and at the end of my rope in regards to prolonged hospital stays. Maybe I’d want to give up and be left alone too. But it’s my job to get them through the tough recovery period so they can go home and enjoy the highest quality of life possible. When faced with a patient in the “wet cat” phase of recovery (I say “wet cat” because they appear to be as pleased to be on the rehab unit as a cat is to being doused against their will), these are the usual stages that I go through:

1. I explain the factual reasons for their admission to rehab and what our goals are. I further describe the risks of not participating in therapies, eating/drinking, or learning the skills they need to care for themselves with their new impairments.

2. I let them know that I’m on their side. I understand that they don’t want to be here, and that I will work with them to get them home as soon as possible, but that I can’t in good conscience send them home until it’s safe to do so.

3. I give them a projected discharge date to strive towards, with specific tasks that need to be mastered. I try my best to give the patient as much control in his care as possible.

4. I ally with the family (especially their wives) to determine what motivates them, and request their presence at therapy sessions if that seems fruitful rather than distracting. (Helpful spouse input: “Mike only wants to walk with me by his side, not the therapist.”)

5. I ask loved ones how they think the patient is doing/feeling and if there is anything else I can do to make his stay more pleasant. (Helpful input: “John loves ice cream. He hates eggs” or “John usually goes to bed at 9pm and gets up at 4am every day.”)

6. I meet with nursing and therapy staff to discuss behavioral challenges and discuss approaches that are more effective in obtaining desired results. (For example, some patients will always opt out of a task if you give them a choice. However, they perform the task if you state with certainty that you are going to do it – such as getting out of bed. “Would you like to get out of bed now, Mr. Smith?” will almost certainly result in a resounding “No.” Followed perhaps by a dismissive hand wave. However, approaching with a “It’s time to get out of bed now, I’m helping you scoot to the edge of the bed and we’re going to stand up on 3. One, two, three!” Is much more effective.)

7. If all else fails and the patient is not responding to staff, loved ones, or doctors, I may ask for a psychiatric consult to determine whether or not the patient is clinically depressed or could benefit from a medication adjustment. Typically, these patients are vehemently opposed to psychiatric evaluation so this is almost the “nuclear” option. Psychiatrists can be very insightful regarding a patient’s mindset or barriers to participation, and can also help to tease out whether delirium versus dementia may be involved, and whether the patient lacks capacity to make decisions for himself.

8. If the patient still does not respond to further tweaks to our approach to therapy or medication regimen, then I begin looking for alternate discharge plans. Would he be happier in a skilled nursing home environment where he can recover at a slower rate? Would he be amenable to an assisted living or long term care facility? (The answer is almost always a resounding “no!”) Is the patient well enough to go home with home care services and round-the-clock supervision? Does the family have enough support and can they afford this option?

9. At this point, after exhausting all other avenues, if the patient is still declining to move or eat or be transferred elsewhere, some sort of infection might set in. A urinary tract infection, a pneumonia, or bowel infection perhaps. Then the patient becomes febrile, is started on antibiotics, becomes weaker and less responsive, and is transferred to the medicine floor or higher level of care. Alternatively at this phase (if he is lucky enough not to become infected) the patient might have a cardiac event, stroke, blood clot with pulmonary embolus (especially if he is a large man), kidney failure, or develop infected pressure ulcers. Any of which can be cause for transfer to medicine. In short, if you stay in the hospital long enough, you can find a way to die there.

10. After much hand-wringing, angst, and generalized feelings of helplessness the wives and I review the course of events and ask ourselves if we could have done anything differently. “If I had acted like a drill sergeant, do you think he would have responded better?” I might ask. “No dear, that would only have made things worse.” She’ll reply. I’ll see how disappointed she is in his deterioration, staring off towards pending widowhood, engaging in self-blame and what-ifs (E.g. “If we had only had more money perhaps we could have taken him home with 24 hour nursing care until he was better…” “If I had cooked all his meals, maybe he would have gained enough strength to avoid the infection…” etc.) I try to be reassuring that none of this would have made a difference, myself reeling from the failure to get the patient home.

This 10 step process happens far more often than I’d like, and I certainly wish there were a way to head off the downward spiral with some kind of effective intervention. Would it help to have a volunteer unit of ex-military peer counselors in the hospital who could visit with my patients and help to motivate them to get better? (Operation “wet cat” perhaps?) Should I change my approach and put on my drill sergeant hat at the earliest stages of recovery to force these guys out of bed? Can educating younger law enforcement and military workers about illness help to prepare them to be more compliant patients one day?

I don’t know the cure for stubbornness, but it sure leaves a lot of widows in its wake.

Motivation Is More Important Than Information At Reversing Obesity

I recently found my way to an interesting NPR podcast via a link from Dr. Ranit Mishori (@ranitmd) on Twitter. The host of the show interviewed a physician (Dr. Mishori), an obesity researcher (Sara Bleich), and a family nurse practitioner (Eileen O’Grady) about how healthcare providers are trying (or not trying) to help patients manage their weight. Several patients and practitioners called in to participate.

First of all, I found it intriguing that research has shown that the BMI of the treating physician has a significant impact on whether he or she is willing to counsel a patient about weight loss. Normal weight physicians (those with a BMI under 25) were more likely to bring up the subject (and follow through with weight loss and exercise planning with their patients) than were physicians who were overweight or obese. Sara Bleich believes that this is because overweight and obese physicians either don’t recognize the problem in others who have similar body types, or that their personal shame about their weight makes them feel that they don’t have the right to give advice since they don’t practice what they preach. While 60% of Americans are either overweight or obese, 50% of physicians are also in those categories.

Although it’s not entirely surprising that overweight/obese physicians feel as they do, it made me wonder what other personal conditions could be influencing evidence-based patient care. Is a physician with high blood pressure less apt to encourage salt restriction or medication adherence? What about depression, smoking cessation, or erectile dysfunction? Are there certain personal diseases or conditions that impair proper care and treatment in others?

Several callers recounted negative experiences with physicians where they were “read the Riot Act” about their weight. One overweight woman said she handled this by simply avoiding going to the doctor at all, and another obese man said his doctor made him cry. However, the man went on to lose 175 pounds through diet and exercise modifications and said that the “tough love” was just what he needed to galvanize him into action.

Dr. Mishori felt that the “Riot Act” approach was rarely helpful and usually alienated patients. She advocated a more nuanced and sensitive approach that takes into account a patient’s social and financial situation. She explained that there’s no use advocating personal training sessions to a person on food stamps. Physicians need to be more sensitive to patients’ living conditions and physical abilities.

In the end, I felt that nurse practitioner Eileen O’Grady contributed some helpful observations – she argued that the rate-limiting factor in reversing obesity is not information, but motivation. Most patients know what they “should do” but just don’t have the motivation to start, and keep at it till they achieve a healthy weight. Ms. O’Grady devoted her practice to weight loss coaching by phone, and she believes that telephones have one big advantage over in-person visits: patients are more likely to be honest when there is no direct eye contact with their provider. Her secret to success, beyond a non-judgmental therapeutic environment, is setting small, attainable goals. She says that if she doesn’t believe the patient has at least a 70% chance of success, they should not set that particular goal.

Starting goals may be as simple as “finding a workout outfit that fits.” As the patient grows in confidence with their successes, larger, broader goals may be set. Weight loss coaching and intensive group therapy may be the most motivating strategy that we have to help Americans shed unwanted pounds. Apparently, the USPS Task Force agrees, as they recommend “intensive, multicomponent behavioral interventions”  for those who screen positive for obesity in their doctors’ offices.

I think it’s unfortunate that most doctors feel that they “simply don’t have time to counsel patients about obesity.” Diet and exercise are the two most powerful medical tools we have to combat many chronic diseases. What else is so important that it’s taking away our time focusing on the “elephant in the room?”  Pills are not the way forward in obesity treatment – and we should have the courage to admit it and do better with confronting this problem head-on in our offices, and also in our own lives.

Paralyzed Man Wants To Know: “What’s Your Excuse?”

I have meet several amazing people at my new job.  Here is one of them:  Richard Vaughn (photo credit).  The poster isn’t accurate any longer, the 12 should read 20.

Richard is the IT guy at my work place.  He broke his back at age 17.  This hasn’t kept him from having a full life.

……Shortly after graduation as a 17 year old, a severe accident – a fall of roughly 85 feet from a scaffolding – left me paralyzed and in a wheelchair. This was in the early 1970s. It was suggested that I enter one of several “special schools” for the handicapped. There, I was told, I might learn a vocation and become a “contributing member of society.” Read more »

*This blog post was originally published at Suture for a Living*

Solving The Health Care Crisis By Understanding The Uncertainty And Variability Of Health Care

Every day in the U.S. countless experts discuss plans and policies to contain the cost of health care using words and concepts that run counter to our (the public’s) experiences with finding and using care. Most of us ignore the steady stream of proposals until one political party or the other crafts an inflammatory meme that resonates with our fears of not getting what we need. At which point, we leap into action online, in town meetings and in the voting booth. As Uwe Reinhardt noted in his Kimball Lecture at the recent 2011 ABIM Foundation Forum, researchers and policy makers “cannot even discuss the cost-effectiveness of health care without being called Nazi(s).”

Our discomfort with the array of private and public sector proposals to improve health care quality while holding down costs should not be surprising. Most of us hold long-standing, well-documented beliefs about health care that powerfully influence our responses to such plans. For example, many of us believe that:

… if the doctor ordered it or wants to do it, we must need it.

… talking about less expensive treatments makes us feel that others are trying to bargain-shop our care and that scares us.

… clinical care does not vary much among our own doctors and hospitals.

… when we talk about the “quality” of health care we are referring to Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

Fear Of Death Can Motivate Patients To Take Their Medicines

As a hospitalist I sometimes come across patients who, for what ever reason, refuse to take the medications prescribed by their in-patient doctors.  Some patients refuse out of fear.  Some doctor told them years ago that taking medication X would make them worse.  Some patients refuse out of ignorance of their disease process.  Most of the time however, they just don’t understand why the medication is necessary.  Some patients just refuse out of stubbornness.  And some patients refuse because they have a really good reason.

However, when you’re dealing with critical illness and the only thing that’s going to save your patient’s life is a treatment plan they are refusing, sometimes you have to be in their face with reality.  So how do I handle situations with patients who have the capacity to make poor medical decisions but refuse life saving medications?  How do I convince my hospitalized patients to take their medications I’ve prescribed? Read more »

*This blog post was originally published at Happy Hospitalist*

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