Why Some Hospitals Are Allowing Unnecessary Suffering

By Maggie Mahar -- BAD, DON'T USE, Health Beat. Posted May 17, 2008.

"His heart filled virtually his whole chest," recalls Dr. Diane Meier describing her very first patient, an 89-year-old suffering from end-stage congestive heart failure. 

It was the first day of Meier's internship at a hospital in Portland Oregon, and after being assigned 23 patients, she was suddenly told that one of her patients, who had been in the Intensive Care Unit for months, was "coding." She raced to the ICU where the resident told her to put in a "central line."

"I didn't know how," Meier admits.  "I felt overwhelmed and inadequate. Then, the patient died ...

"Everyone just walked out of the room," she remembers.  I stood there. I still sometimes flash back on that scene: the patient, naked, lying on the table, strips of paper everywhere, the room empty. This was my patient. I felt I was supposed to do something -- but I didn't know what."

Meier left the room and, in the hallway, saw the patient's wife. "I walked right past her," she recalls, nearly shuddering at her own cowardice.  I didn't know what to say. I didn't even say 'I'm sorry.' As a physician, I didn't think that I was supposed to do that. "

I heard Dr. Diane Meier tell this story at a conference for medical students at  Manhattan's Mt. Sinai School of Medicine last week. When she finished, she asked her audience, "What is the hidden curriculum here? What does this story tell you?'

"Once the patient dies, he no longer matters," said one student.

"If we can't save the patient, the patient doesn't matter," added another.

Meier drew a third lesson: "Before he died, this patient had spent two months in the ICU. We had done everything possible to prolong the dying process."  As a doctor, you have to step back and say, 'What is this experience telling me, and is this right?'"

As a palliative care specialist, Meier spends much of her time with dying patients.  For many, "palliative care" offers a middle road between pulling out all the stops and simply giving up hope. Like traditional "hospice" care, palliative care focuses on "comfort" rather than "cure," emphasizing pain management and easing the emotional trauma of facing death, both for the patient and for the family.  But palliative care also includes procedures aimed at treating the symptoms of the disease.

In the past, Meier explains, physicians have seen caring for a terminally ill patient as an "either/or" situation: "Either we are doing everything possible to try to prolong your life -- or when there is 'nothing more that we can do,' only then do we make the switch to providing comfort measures. This dichotomous notion -- that you can do one thing alone and then the other thing alone later -- has nothing to do with the reality of what patients and their families go through."

In her talk last week, Meier explained that her first patient was one of three who marked turning points on her life as a physician. Originally, she trained to become a geriatrician, a doctor who cares for people over 65.  "I think because I was very close to my grandfather," she explained, "and because I'm a 'lumper' not a 'splitter'," she added, referring to the distinction between doctors who prefer to treat the whole patient, head to toe, and those who prefer to specialize in a body part: the foot, for example, or the eye.'

Her interest in treating the elderly brought her to Mt. Sinai, which, at the time, had the only Department of Geriatrics in the country.  But as her career unfolded, she found herself "become more and more alienated from medicine. Here, in the hospital, everyone was running around, ostensibly trying to help the patient, but actually often hurting the patient. I thought about quitting. I had a fantasy of opening a bakery/book shop where I could read and eat brownies ..." she told the med students.

"Then I met a patient I will call Mr. Santanaya."

Meier first encountered Santanaya when she was walking down a hospital hallway and  heard a man screaming and moaning in pain. She looked into his room and there he was, pinioned to his bed, hand and foot, in "four-point restraint."

"I went to the nurse and asked, 'Why is this man in a four-point restraint?"  The nurse called for the intern.

"I'll never forget this kid's face," Meier recalled "To me, he looked about twelve years old. And terrified.

Meier asked the question again,  and the intern explained: "He has lung cancer that spread to his brain and he's delirious. We put a feeding tube up into his nose and down to his stomach, and he pulled it out. So we tied his hands. Then he pulled it out with his knees and feet -- so we tied his knees and feet."

See more stories tagged with: geriatrics, u.s. medical system, dying, death, health care, health, patient care, hospitals, palliative care, pain

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