Running to Cover: Patient-Centered Care as an Inpatient Rounder

Running to Cover: Patient-Centered Care as an Inpatient Rounder

Don S. Dizon, MD, FACP

@drdonsdizon
Mar 21, 2016

She had been admitted overnight: a previously healthy 62-year-old woman who had been blindsided by acute onset of abdominal bloating and pain 6 months prior. A flurry of tests showed she had pancreatic cancer, and that it was advanced. She had started chemotherapy, but the regimen was so toxic; she suffered from unrelenting nausea and fatigue to the point that in the last 6 weeks she had gone from playing tennis every weekend to becoming unable to rise from bed. In the last 24 hours her family witnessed a significant decline. She was awake only sometimes, and when she was, she was incoherent. This prompted her admission.

I was on service then, and even though much time has passed, I still can see her face. With IV fluids and the correction of some lab abnormalities, she had “woken up”—able to speak to her family and clearly aware that she was in the hospital. I saw her the next morning and asked how she was doing.

“Well, I could be better!” she stated. She told me about how the pain had gotten worse recently, that chemotherapy was making her feel worse than before, instead of better. “I had no idea it would be this hard.” We had also done a CT scan, which showed the worst: the cancer was now in her liver, where multiple sites of metastases had grown despite chemotherapy.

Because I am not an expert in upper gastrointestinal cancers, I reached out to her primary oncologist. As we spoke, there was sadness in his voice that his hopes for her were not being realized. He had hoped to alleviate her suffering with chemotherapy but had been frank with her that the cancer was too advanced for surgery and that our treatments would not induce a remission, just—hopefully—give her more time. Unfortunately, he was also away at an international meeting and would not be back for the rest of the week. I told him about the CT scan, asked him his opinion.

“I think her options are really limited, especially since she feels so poorly. I think she needs to know she’s dying,” he said.

At that point I felt a discomfort—because it was my turn to be the inpatient rounder, somehow it would fall on me to deliver this news. As we talked I thought about asking him who would tell her. Surely, there was someone covering his outpatient practice. Surely, there was someone in his group who could break this news. Couldn’t his nurse practitioner do it?

But then I thought about her. That she needed to know the results of her scan and what it meant. That she deserved to meet with someone sooner rather than later. That absent her primary oncologist, she deserved to meet with someone who had the time to sit with her and her family.

Oncology has evolved so much, with better treatments and better supportive care options, that much of what we do, we do in the outpatient setting. Our clinics tend to be filled with patients, making the task of caring for those in the hospital so much harder. At MGH we have sought to meet the needs of our patients both in and out of the hospital as many other institutions have done: by assigning an attending as rounder. It becomes the rounder’s responsibility to oversee the care of patients, to have meetings when needed, and to establish plans for acute levels of care. Most times, a patient’s outpatient attending can be called upon to meet with the patient and their loved ones, especially if one is at a critical point in their own cancer journey. But, as is often the case in a busy academic practice, sometimes it’s just not possible. And this was one of those cases.

So to my colleague, I simply said, “I will take care of it, if it’s okay with you.” He thanked me for this, and then hung up.

With that, I made arrangements to meet with her and her family, alongside her entire team of palliative care clinicians, nurse, nurse practitioner, and social worker. Together, we told her what we knew and what she needed to know—that her cancer had progressed, that treatment was not working, and that we feared she was dying. She had expected as much, especially since she had seen herself declining so rapidly. We decided together to stop chemotherapy and transition to end-of-life care, with a focus on comfort measures and symptom control.

In a system of inpatient rounders and busy outpatient clinics, sometimes patient-centered care can be difficult to aspire to. But holding on to our own humanity, maintaining empathy, and remembering that each patient has a name, a family, and their own story helps to remind me just how important the task is. So, as rounder, I have learned to treat each inpatient as my own—even if it is only for 2 weeks.

Our patients expect this of all of us, and I have learned that my colleagues and I expect it of each other.

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Comments

Nathan A. Pennell, MD, PhD

Mar, 21 2016 4:40 PM

It is so easy to put something important like this off, to defer to the outpatient oncologist even if they are far away or not available for some time. If the patient is fine and can wait, then I do think the relationship with the primary oncologist is important and this should be their job if accessible soon. However, when the patient is sick and the course obvious, this is an important responsibility that the inpatient oncologist should take on but often doesn't. All too often I have seen patients bouncing from inpatient stay to inpatient stay and not even make it to an outpatient appointment to have "the talk". Well done sir.

Don S. Dizon, MD, FACP

Mar, 22 2016 9:00 AM

Nate, Thanks for commenting! I agree- it is easier to turf responsibilities to outpatient colleagues in such situations; they know their patients and often, want to be there to have these talks. In the academic settings we both practice in, however, it is not physically possible at times. I am fortunate that I can honestly say I trust the judgments and decisions of my colleagues in the MGH Cancer Center- and I know that they will care for my patients as I would myself. It is this reciprocity of responsiblity that makes inpatient rounder an important experience- and no one should feel that they are being short-changed- especially that patient and her/his family. Best  to you and see you in Chicago! D

Caroline Mawer

Apr, 08 2016 4:30 AM

Thanks for sharing. And thanks even more for doing the right thing! But, for me, the most interesting / challenging sentence in your blog was "She had expected as much, especially since she had seen herself declining so rapidly." Then I wondered, just wondered, whether she might have been even better served by having had a similar conversation earlier? I also thought about how lonely and probably frightening it must have been for her, 'expecting as much' all by herself. Ditto her family. Of course the transition into 'comfort' care is always going to be difficult. I know that this lady was not 'your' patient. I also know the sensitivities around saying anything that might be seen as a criticism of colleagues. I would like to say here very clearly that my comment here is not a specific criticism of anyone. After all, a blog cannot get over all the details of any case. But this lady's oncologist apparently wanted to "alleviate [the patient's] suffering with chemotherapy". When the lady told you that the chemo was making her feel worse rather than better. I'm a doctor in the UK, and I understand that the US system is more 'heroic' at the end of life. But even so, more of your sort of communication is always going to be a good thing! 

Don S. Dizon, MD, FACP

Apr, 08 2016 7:58 AM

Dear Caroline, Thanks so much for your comments! One of the difficulties with rounder is not being fully aware of the relationship and conversations of a patient and her provider before admission. I am certain in most cases, as in this one, there was a long established relationship and even with the best documentation, the subtleties of that relationship and past conversations are not readily captured. One has to do what is best though- even when those patients are not under your own longitudinal care. Communication is the key, though- and being willing to "act" as her attending, even when you are not the long-term attending she has known. Welcome to Connection! D

L H

Apr, 08 2016 12:40 PM

As the caregiver of a loved one who has died from cancer, I can assure you that you are absolutely on the mark.  The family was not informed that the patient was dying until he was receiving palliative sedation.  The patient was never told.  One of our greatest regrets was that we were unable to provide comfort to him at a time where surely he knew, at least intuitively, that his condition was worsening rather than improving.  It is especially difficult for us to know that had he been told his time was limited earlier, he could have achieved at least some of the things that were important to him in the last months of his life.  

Don S. Dizon, MD, FACP

Apr, 08 2016 12:49 PM

Dear LH, I am so sorry of your experience and yes, I agree that the saddest part is not being able to live out your wishes, especially when you arent fully aware that end of life is near. I find that patients often have a sense that things are not going well, but need to hear that is the case from their doctors- not so much as a validation, but as justification of what they might already know. I hope your loved one knew how much you did indeed love him and knowing that you were there by his side, even when he was sedated, brought him comfort. Peace always, D

John Abraham

Apr, 08 2016 12:42 PM

I lead the AZ Affiliate of Final Exit Network and as a Thanatologist I'm an expert on end of life issues.  Thanks for doing the right thing!  More often than not, someone who is dying knows it -- discussing this reality is another matter.

All too often we engage in treatments and proceedures that do little or nothing to extend life or improve the quality of that life, with great emotional, physical, and finacial stress to patient and family.  It is important to recognize that there comes a time to die, and for one's death to be as comfortable, dignified, and peaceful as possible.

Don S. Dizon, MD, FACP

Apr, 08 2016 12:50 PM

Dear John, thanks for posting. I agree- having a sense you are dying is not the same as having the conversation acknowledging that that is the reality. I appreciate your thoughts and share the goal you wish for all- to die with comfort, dignity, and peace. D


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