Would you be surprised if this patient died within the next 6 months?
It was my first week of inpatient medicine, and I was peering over the intern’s shoulder as she clicked around Epic, filling in all of the information we had just obtained from our new admitted patient down in the ED. Medications: reviewed. Problem list: reviewed, updated. Surgical history: reviewed. The question popped up; to me, it seemed sort of jarring. We’d known the patient for 20 minutes. Were we qualified to answer this based on the first-week-of-clerkships-level history I got from the patient? At the same time, I felt relieved by the next click of the mouse, relieved by her response. Yes. She would be surprised.
On my Medicine clerkship, I learned… a LOT of medicine. Standard, universal, well-validated medicine. Illness scripts, calculations, differential diagnoses for common inpatient problems, how to interpret labs, when to call consults, what tests to order and when to order them. I was taught which clinical apps to download and when to use them, the best websites for evidence-based recommendations, and the standard protocols for ACS and pulmonary embolism rule-outs. So many aspects of inpatient medicine had an answer, and by the end of my first month, I either knew the answer to a clinical question, or I knew who to ask, where to look it up, or how to calculate it myself.
During this time, I also learned an infinite amount–but not nearly enough–about the nebulous aspects of medicine. The untouchable, undefined, humanistic, ethical, existential parts that can be uncomfortable to approach and impossible to master, especially when expertise is expected in so many other aspects of medicine. The parts with no algorithm, evidence-based solutions, no definitive next step. The parts that I was told to pick up the phone and reach out for help with. Can we loop in the palliative care team? Maybe Psych should come see the patient? Is this a question for Ethics? Maybe the previous outside hospital had a better grasp on what might be going on. Can you call the sister and set up a goals of care discussion?
“Goals of care” was particularly undefined. Throughout my time on inpatient medicine, I heard these 3 words several times a week. Where should we go next with a patient’s care? What would they want? How can we individualize their plan of care to meet their physical, emotional, and spiritual needs and values during a time of serious illness?
Doc, I just need to get home.
My father would never want to be kept alive under these circumstances.
This is not the quality of life I want.
We just want to keep him here, alive, with us.
There was seldom a right answer or easy solution; we could only take what the patients and their families highlighted as important to them and shape our plan to match their needs. We often discuss goals of care as a patient’s condition is worsening in the hospital, but less often when they are arriving from the ED seemingly not “sick”, or when they are healthy and stable outpatients in the clinic–we seem to do a lot less “goals of care” when the patient is farther from the end. On top of that, advanced care planning, end of life discussions, and feeling uncertain about the next best step isn’t covered much in the science-filled years of pre-clinical medical school.
I found myself inserted into a few goals of care and terminal illness discussions. I felt unequipped, with no evidence, algorithms, or clinical experience to fall back on. In one particular case, the resident and attending delivered the news in the most empathetic way possible and offered to involve the palliative care team. Palliative care? I don’t think I need that doc, I know this is the end. This is it, right? The rest of the team reassured him that they would make him as comfortable as possible in his remaining days. And what do you think? The patient turned toward me and raised his eyebrows, awaiting my input on his predicament. I felt hot under my PPE, racking my brain for what tangible support I could add. What do I think? In the end, I needed only my compassion, empathy, and human experience. Some things, we are not experts on.
Would you be surprised if this patient died within the next 6 months?
By the end of my first month, we had answered that original question wrong a few times. Patients who had come in, acutely ill, but with complaints that I was sure we could handle based on my studying and experience so far. Shortness of breath? We have tools for this. Foot ulcer but otherwise walking and talking just fine? We know how to work this up. I found that, sometimes, we didn’t know the next step, or the right thing to do, or the root of the patient’s symptoms. We didn’t know what their prognosis would be, or what their quality of life would look like on the other side of this admission. We didn’t quite know how to grapple with the things we have no personal experience with or algorithm for, like end-of-life issues or what it means to live a good life. Our intentions were infinitely good yet often limited by the finite degree of medical knowledge and human insight.
Medicine is unpredictable, humbling, and just when we think we have a grasp on things, we are surprised by how little we know compared to the vast expanse of physiology and complexities of human existence that we have yet to decipher. The humility and introspective awareness that we will not always know the answer or the best thing to say, is a strength in itself.