Medical Entropy – Peter S. Kibbe, MD, FHM

I find myself involved not infrequently with medical cases in which a declining patient suffers a primary insult and then starts down a medical, surgical or “rehabilitative gyre” of complications: therapy followed by complications of the therapy given to treat the complications of the therapy.  The analogy would be that of a log flowing downhill from a peaceful creek, encountering a small eddy, twisting and turning as it gained speed in its downward spiral.  This often involves a person of very advanced age or an older patient with multi-organ disease.

At times we generalists encounter these patients in the last phases of one of these cascades.  A recent case comes to mind of a woman in her late eighties who at baseline had ambulatory dysfunction, obesity and atrial fibrillation treated with anticoagulants. She had suffered a fall with a complicated fracture of the ankle region. She underwent surgical repair of the fracture, then complications arose with anticoagulants employed for DVT prevention and her atrial fibrillation.  She was transferred to a skilled facility where her rehabilitation did not go well.  She developed pneumonia which was presumed to be health care associated, went on the usual antibiotics for the same and returned to the nursing home where she remained bed bound.  At the nursing home she developed C. difficile colitis, failed management as a patient there and was again hospitalized.  She failed hospital treatment for C. difficile and began to go into renal failure and heart failure.  She underwent colonoscopy for diagnosis and instillation of Vancomycin directly into the colon.  She was attended to by multiple sub specialists and her code status was DNRcc A.  Due to dysphagia she was placed on total parenteral nutrition.  I was called to see her when I was filling a day in the schedule for another doctor.  Her ventricular rate was slowing, the nurse was worried.

I use the word “entropy” to describe this sort of scenario because clinically the patient as an organism, and the medical care being offered, appear to be descending into disorganization.

The elderly bones cannot tolerate relatively minor trauma, the lung becomes infected, the immune system cannot tolerate antibiotic treatment, the kidney fails and then the heart forgets its duty. She had slipped into a delirium. There is no end to procedures, medications and devices for each one of these events.  Short of her heart ceasing to function at all (her resuscitation status is dnrcc A) she can be subject to any procedure; she could presumably be a candidate for surgery, a pacemaker, a left heart catheterization, hemodialysis, each one adding further threats of complications.

When I saw her she was uncomfortable, lethargic, moaning and unable to verbalize well enough to discuss her multiple problems.  Her daughter who was her medical POA was at the bedside.  In terms of patient and family communication technique, how would you proceed?

I have no algorithm for this, but I think in this kind of case, when you can only know what could be seen from the medical record, it is important first to listen to the daughter who has been caring for this person and who is now the decision maker.  “Tell me what has happened to your Mom in the last few months,” is a good starting point.  Do so in the manner of pure inquiry without judgement. The decision maker’s perception of what has been happening and expectations of care then often become apparent.  In this case the daughter was very aware of therapeutic failure.  Another good question, after you have listened to that person is to find out what kind of person the patient was and what preferences that patient had regarding medical care at an advanced age.  “Did your Mom ever talk about what kind of care she wanted if she became so very ill?”  I have been surprised how many times I have heard statements such as, “Well, she never wanted this.” (When I hear this it dawns on me that no one has ever asked.)  You can then have a conversation regarding goals, which goals the family has and whether they are

realistic.  If their goals are unrealistic you can use the “I hope but I am afraid” statements: “I hope we can get your Mom back on her feet, but I am afraid it might be too much to expect of her with the multiple organs that are failing her.”

If you are under the impression that the patient has no hope of what the patient and family would call a “meaningful recovery” you can proceed to a discussion of palliative care.  Most people do not know what this is and it needs definition.  I like to emphasize that it is care that devotes itself to the comfort and dignity of the patient and to management of symptoms in a non-invasive way.  It is a conversation that every hospitalist should have, in a sense, rehearsed and ready, so that the family understands it is an end to the tethering of the patient to monitors, an end to laboratory investigations and procedures and an end to external means of organ replacement.  If the family is concerned regarding hunger and thirst you need to be prepared for that conversation.

When I encounter patients such as this one I am reminded of Yeats’ opening verse to his poem, The Second Coming:

Turning and turning in the widening gyre

The falcon cannot hear the falconer;

Things fall apart: the center cannot hold…

In falconry the hawk or falcon is trained to hunt by a falconer, and hunts by flying in circles (gyres) above potential prey, directed by calls from the falconer.

We often become like the falcon of the poem, medically proceeding through our “widening” gyres,    neglecting to listen or try to hear the patient or her kin.