Friday Reflection 51: Failing in Place

VL is a 97-year-old man admitted to the hospital for the third time in six months. The first admission was for a scheduled procedure. The second was for a late complication of that procedure. The most recent was for non-specific symptoms on a hot summer day.

During the first two admissions, the medical team and the physical therapists recommended that VL be discharged to a sub-acute rehab facility as they were concerned about his safety at home. He adamantly refused and insisted on being discharged home. Soon after both discharges, VL fired the home health agency that had been set up to provide home support.

Very commonly, a doctor’s greatest strength is also his or her greatest weakness. Given the number of phrases to describe the phenomenon – a double-edged sword, a boon and a bane, the paradox of strength and weakness, a mixed blessing – this should not be a surprise.

A doctor might have a grasp of impressively broad differential diagnoses. The breadth of these differentials paralyzes her when it comes time to make a final diagnosis. A doctor might attend to every patient's every complaint, never missing a “must-not-miss diagnosis.” This same doctor admits healthy patients to the hospital to exclude profoundly implausible diagnoses. And then there is the wise and knowledgeable doctor who is comfortable saying, “I don’t know.” Patients abandon his practice after losing confidence in him, having spent too many visits researching topics on UpToDate together.

I consider one of my strengths to be my willingness to respect patients’ wishes. Once I have explained my recommendation and its rationale, once I am sure that I have been understood, I will accede to patients’ wishes that are contrary to my own. The most forceful I will be in trying to sway their decisions is to say, “I think you are making the wrong decision.” I tell myself, “This person is an adult; she has the right to make her own decision, even if I think it is a bad one.”

I am proud of this strength. Several patients have told me that they see me because I respect their wishes. Patients have said to me that they transferred their care to me because they did not appreciate the brow-beating that a former doctor subjected them to.

However, my approach is also a weakness. My willingness to accept my patients’ wishes allows them to be treated less aggressively than is warranted. It would not surprise me if my patients' LDL levels and systolic blood pressures were higher than those of my peers. It would not surprise me if they are on less GDMT, are less likely to get flu shots, and get fewer mammograms.

Sometimes I think my practice reflects my understanding of the small absolute benefit of many of our interventions, as well as the wisdom I have gained over decades of practice. Other times, I think my practice reflects clinical inertia and fatigue, borne of decades of clinical work.

VL presented a quandary that I encounter frequently as my practice has matured. His third hospitalization of the year was avoidable. After his daily walk, on a particularly hot day, he decided to skip some of his medications. It was probably a combination of the heat and poor adherence that led him to feel poorly and a little confused. When he called his relatives, who live in the suburbs, and couldn’t reach them, he panicked and called 911.

After a few hours of TLC in the ER, he could have gone home. The ER doctors, however, were appropriately concerned with the state of his apartment as described by the EMTs.

Sitting at VL’s bedside, the morning after admission, we discussed next steps. I told him that with each visit, and each hospitalization, I’d become more worried about him. I told him that I no longer thought he was safe, living alone in a one-bedroom apartment on the second floor of a walk-up building. I thought he would be safer going to a sub-acute rehab, and probably then transitioning to assisted living, if not a nursing home.

“Dr. Cifu, you know me, there is no way I am not going home. I wouldn’t last a week at one of those places. We know I don’t have that long left. My niece calls me every day. Maybe one day I just won’t answer. Maybe I’ll fall and break a hip. So what? If that’s how it will end, then that’ll be the end. Neither of us knows what is going to happen.”

“It sounds like you’d rather be happy at home than safe at a rehab?”

“Yup.”

I thought of our conversation when I read a recent Viewpoint in JAMA, A Call for Improved Strategies to Support Aging in Place: The Hackmans’ Story. The article addresses people’s desire to spend their later years at home and the challenges with achieving this, using the death of Gene Hackman as a hook.¹ The article didn’t tell me anything I didn’t already know, but it made me a little concerned that my willingness to yield to people's wishes might lead to unsafe situations.

When I am feeling self-assured, I can contend that aging is not a disease we can treat, that death is unavoidable, and that with even the most extreme efforts, crises at the end of life are often inevitable. Sometimes it takes a crisis to stimulate a necessary change.

Sometimes the crisis will just be the end.

When I am feeling less self-assured, I wonder if by deferring to patients’ poor decisions, I put them at risk. The authors describe Hackman’s end as “unimaginable horror.” Yet, when they discuss means of prevention, they write of “In-home cameras or other developing artificial intelligence technology (that) may allow for outside monitoring” and “allowing strangers to enter their homes… to witness them at their most vulnerable.” These options make me recoil.

VL’s niece picked him up and brought him home. I called him a few days after discharge. He told me that he liked the nurse who made the first home visit. A home health aide is scheduled in the coming days. He promised me he wouldn’t fire them. I am scheduled to see him next week.

My fingers are crossed. I expect this story will have a bad ending.

1. The hook got me. Gene Hackman died in Santa Fe, where my wife is from and where we visit frequently. I also recently watched The French Connection on a flight, as well as Hoosiers and The Royal Tenenbaums. If you want my advice, The Royal Tenenbaums is the best of the three.