A difficult but important conversation

In the Medical ICU, medical students are part of a team that manages patients with serious and complex medical problems, including learning how to have difficult conversations with patients and their loved ones. There are frequent family meetings to discuss patient prognoses, recovery timelines, and goals of care. The team aims to do everything that the patient would want, be it everything, nothing, or something in between.

This is where issues can occur – healthcare providers and family members may be unaware of the patient’s wishes and the actions taken on behalf of a patient.

Triathletes, runners, and cyclists are fit and healthy individuals who expect to live for many more years. Unfortunately though, accidents happen, and the unexpected can force family members to make difficult decisions about the care of a loved one.

During my time in the ICU, I have seen families struggle with making these decisions. The stress of making a life-changing decision for someone else is very difficult. These decisions can be made much less difficult if the patient has a very clear written living will that allows the family members to make decisions in accordance with the patient’s wishes. In the situations I’ve seen, families derive a great deal of comfort from knowing that the decisions they are making reflect what the patient would want in that situation, even if the patient cannot advocate for him/herself at the time.

I encourage you to have a conversation with your loved ones about what you want if you are not able to make medical decisions for yourself. Do you want a breathing tube? Do you want to be on life support? If so, for how long? Do you want a feeding tube? Do you want CPR done? This is called a living will, and it helps your loved ones and physicians make the decisions you would want. Having a succinct and clear written living will also decreases disagreement among family members.

Another important designation to make is your power of attorney, also known as healthcare proxy. The appointed person will make the medical decisions for you if you are incapacitated. If no power of attorney has been established, there is a set order created by your state of who will be responsible for making healthcare decisions for you. Some states also limit how far their decision-making power goes. In contrast, a healthcare proxy can make all of your medical decisions, including end-of-life care. It is important to have this in writing (links for forms and more information at the bottom of the post) because you may not be able to share your wishes due to stroke, severe injury, neurological status, etc.

As an example, because I am healthy, I would want CPR done. I want everything done that can be done for me. If I need life support, I will give it 7 days. If I do not start to improve after 7 days, I want to be taken off life support. Why 7 days? It seems like a solid number – enough time for my body to heal some and make some progress, but not that long of a time on a ventilator. As I grow and change, my living will will also change. I expect at some point to not want any heroic measures done. The good thing about a living will is that it can be updated by the creator to meet the changes in his/her life.

Below are good resources for how to establish a living will, designate a power of attorney for when the need arises, and how to have this important conversation with family members. Most hospitals, nursing homes, and home health agencies are also required by federal law to provide information about and the necessary forms for living wills and power of attorney.

The Mayo Clinic – The basics on living wills and different methods of resuscitation

National Hospice and Palliative Care Organization – Advance Care Planning – Good resource on how to talk to family members, your state’s requirements for advance directives, and how to prepare one.

National Caregivers Library – Good resource for everything about power of attorney.

American Bar Association – Good resource from the lawyer perspective. If you scroll about half-way down, there is a box called “Featured Resources.” These PDFs are very good resources for the patient and the proxy, and also includes financial guidance information.

“But it’s good for me”

I recently finished my Surgery rotation, which consisted of 4 weeks on GI/Bariatric, 2 weeks on orthopedics, and 2 weeks on ear, nose, and throat. I loved being in the OR. I also loved clinic, and seriously considered changing my career path to Surgery. However, my triathlon had to take a back seat during my 12+ hour days, and I found myself being unhappy when I was not in the OR. Surgery made me take a step back to evaluate what makes me happy, and I find sport to play a pivotal role in my happiness. I love being part of a team and training and interacting with people outside of medicine. Don’t get me wrong, I love my medical peers and supervisors – they are awesome people – but being able to not talk medicine is fantastic. When medical students hang out, we talk about studying, interesting cases, and how stressed we are for the upcoming exam (there is always an upcoming exam). I also love getting away from academics for at least an hour a day to just be and think about whatever I want. Triathlon has become my therapy during medical school.

Of late, though, I have found myself defending my decision to compete in triathlons. When fellow medical students, residents, and attendings find out I do triathlon, they often question how I find the time for it and question my dedication to the field of medicine. My usual response is triathlon and racing is a part of my life I cannot imagine living without. It keeps me happy and motivated in school. It provides structure, normalcy, and regular contact with non-medical professionals. I remind people that many medical students have families. No one questions a student for taking a few hours to go to the park with her child. I remind them that I choose to spend my few hours when I’m not studying, training. If anything, triathlon is helping shape my interests in medicine.

In the same vein, when an administrator found out I do triathlon, he questioned how it was helping me become a better physician and implied that I was not focusing enough on school. I brushed off the conversation, but it got me thinking about the larger picture and my mental health. It is estimated that 1 in 4 medical students have a major depressive episode during medical school. According to the American Foundation for Suicide Prevention, physicians have an increased rate of suicide compared to the general population, especially women. Female physicians commit suicide 2.5 to 5.7 times as often when compared to the female general population. During orientation, we had talks from student health, counseling, and well being about the rate of depression and suicide, and that they were all there to help if we ever felt overwhelmed. I believe that the best way to fight depression for me, is by being proactive. Exercise is associated with increased well-being, and triathlon makes me happy. While some individuals will doubt my ability to do school and sport, I know there are many who support me and will continue to surround myself by those who currently do.

Dear patients, thank you

Disclaimer: All patient identifiers and specifics are omitted to maintain patient confidentiality and comply with HIPAA.

***

I wake you every morning at 6:30 AM to examine you and see how your night went. In the afternoon, I take you for a walk around the unit to help you maintain your strength. We talk about the business you used to own, your family, and your favorite sports teams. When we return to your room, I help you finalize your applications for healthcare and food stamps (I know you cannot afford the 3,000+ calories you eat in the hospital.). Back in the team room, I find a small amount of research on a novel therapy, and suggest it everyday for over a week. When all other causes are ruled out, the attending agrees to try the new therapy. Within 24 hours you have improved and you leave the hospital soon after.

You taught me to fight for my patients.

***

As I read through your referral documents, sadness washes over me. You are 89, with metastatic lung cancer to the brain. I prepare myself for goals of care discussion – an 89 year old individual rarely has the health and strength to go through radiation and chemotherapy. But when I walk into the room with my attending, you look 70. I learn that you have zero health problems, you are active in your community, live on your own, and still drive. Your memory, concentration, and math are incredible. After the exam, we discuss treatment to keep your symptoms at bay. Everyone knows we cannot get rid of the cancer – it is too far along – but we can make your life relatively normal. You will dance at your grandson’s wedding.

You taught me to treat the patient, not the number.

***

You came to the psychiatry residency clinic for a new patient evaluation. Within an hour, I know more about you than your best friend does. I am surprised by your willingness to tell me your secrets, but at the end of the session, I see a weight lifted off your shoulders – you are no longer carrying the burden alone.

You taught me to never take for granted or underestimate the trust patients have in their healthcare team.

***

Everyday I see and help treat individuals who do not have to let me examine them. They tell me their secrets, show me odd rashes, lumps, and bumps, and let me see them at their most vulnerable. Without patients, my education would be four long years of memorization, and I would lose the most important part of my education. I would not learn how to tell a patient’s family that Grandma will pass away soon. I would not learn how to ask the “sex, drugs, and rock and roll” questions. I would not learn to treat everyone, not just the patient. My patients teach me so much, and for that I am forever grateful. Thank you, to everyone who makes the choice to come to a teaching hospital instead of a private one. You are the teachers of the next generation of physicians.

In any relationship, there must be trust. There is trust between patient and doctor and there is trust between athlete and coach. The patient wants to feel better, and the athlete wants to get faster and stronger. Once the doctor or coach has accepted responsibility for their charge, it is taken for granted that even on a personal level, they will do their very best for their patient or athlete.

The more medicine I study, the clearer it is that trust and constructive social interactions underpin successful practice in any field. I have been a part of smoothly functioning medicine teams and teams that stumble through morning rounds due to differing opinions. Likewise, we all know the great success stories of sports teams coming together to overcome great odds (US Men’s Hockey team winning gold in the 1980 Winter Olympics, anyone?), and we have all witnessed teams crash and burn. This is why I am so happy to be on the USMES team and coached by Kyle Pawlaczyk – I have found a team and coach I embrace and trust, who provide incredible support, and stand behind my goals of being a professional athlete and doctor.