About a year ago I made a house call to an elderly widow which has left a lasting impact on me.
Our “trusting relationship” began twelve years earlier while I attended to her dying husband at home. She couldn’t find another doctor to come in to help. Now it was her turn to need help, and like her husband insisted that she stay at home. The woman was being cared for by her middle-aged granddaughter who remained her daily companion.
Both granddaughter and grandmother distrusted the health care industry and had formed many conspiracy theories. They believed in the power of healing through “the Lord” and natural remedies, especially vitamins. I admired their fierce independence while holding my tongue on the magical and, in my opinion, misinformed views of the science of medicine. Both tried, in vain, to convince me that I should use the vitamins and other products they endorsed for my patients. I smiled obligingly, yet made no move to implement these ideas while pondering the paradox and danger of being invited into the “trusting circle” of such divergent world views.
When I arrived for the house call, it was evening and I was invited back to see the infirm matron. She had recently suffered an osteoporotic lumbar compression fracture that limited mobility. She was becoming increasingly bed bound despite her determination. The natural consequence for fierce independence meant her granddaughter often was frustrated and foiled.
Grandma resisted every prescribed treatment including taking medicine for her hypertension except vitamins. The Lord and natural ways were all she needed. At the visit, her blood pressure was very high (200/140) and my impression was not good.
My notes documented:
Assessment: Heart rapid irregular rate= tachyarythmia with Atrial fib
Anticoagulation on Coumadin with no recent INR.
Hypertension severe poorly controlled
I decided it was time to read her the riot act.
Plan: Long discussion. She refuses any treatment for hypertension or for her pulse rate. I reviewed that she is at a significant increased risk of stroke. She says that she prefers to not use anything at all despite the risk. She agrees to having her INR checked. I did convey to granddaughter the findings: blood pressure and pulse which are quite worrying. They confess that they would never take grandmother to the emergency room they have all decided mutually that they will only do homecare. I will arrange for visiting nurse to come and check her Coumadin or PT and INR levels.
Of course, the note is just the tip of the iceberg of the persuasive words, reasoning and pleas I used to try to convince her to start using her BP meds. I explained that I could lead a horse to water but I could not force her to drink. In the end we all live with the benefits and risks of our decisions we make.
Sadly, the patient suffered a predictable stroke a month later and developed a thick paralysis on her left side. Uncharacteristically, grandmother and granddaughter cried “Uncle” and finally used the support of the hospital to care for her. She was discharged home and over the year made very little progress. She remains bed bound and needs a lot of personal attention and assistance to meet her daily needs.
Not long after, our nurse practitioner was asked to take over her care because “it cost less” for her time than mine, an understandable decision. On one visit, our nurse practitioner, Valerie Tinley, discovered the deeper reason for the transfer of care: “She blames you for her stroke, and says you told her she didn’t need her blood pressure meds anymore and that it was ok with you to not take them.”
Yesterday, I was marveling with the plasticity of human memory with a lawyer friend when she switched my playful musing into stark fear: “Are you sure your records said ‘stroke.’ For instance if your notes only say the words “heart attack” and you failed to write the word ‘stroke’ she could sue you for failure to adequately warn her claiming that had she known a stroke was possible she surely would have taken her medications. It doesn’t matter what you told her it only matters what’s documented.”
I raced home and read through my medical notes (above). “Thank God,” I thought, “At least she didn’t have a heart attack.”
I then remembered my friend, Iain Allan, who is a Kenyan safari guide. He once was sued by an American client who was attacked by a hippo while on a walking safari that Iain was overseeing. The animal was shot, her life saved, but she suffered a foot drop as a permanent reminder. The waiver she signed before the walking safari began listed many dangers and risks of walking in the African bush including life threatening snake bites, lion attacks, and large mammals like elephants, hippos and water buffalo that are known to be extremely dangerous even lethal to human trespassers. But nowhere on the waiver was there ever a mention that hippos could run so fast. Certainly, according to the affidavit filed by the plaintiff, the exclusion of this claim led her to make a brash, dangerous and uniformed decision — for sure–to ever venture into the bush with trained, armed and experienced guides.
This then is world we live in today. In the future I need to tell the next person who is working hard to ignore or downplay medical advice on top of everything else I might say and the volumes notes and words I must also add the Hippo defense: “WARNING: Hippos can run really fast. Be sure to take your medicine and follow your doctor’s advice to the letter or the hippo will ruthlessly run you down. Permanent injury even death could result.”
I’m sure patient compliance will skyrocket with this warning. I’m also 100% certain there are herds of lawyers clever enough to make a living by finding a way around that warning too.
Until next week, I remain yours in primary care,
Alan Dappen, MD