Hospital Intolerance – Peter S. Kibbe, MD, FHM

Recently I was called by an emergency department physician regarding a patient of about ninety years who presented with shortness of breath.  His shortness of breath improved with inhaled bronchodilators but he then developed atrial flutter and due to changes in his ST segments a “code STEMI” was called.  There was a slight elevation of his troponin and the cardiologist arrived.  He wisely demurred, opining that this was not a STEMI but demand ischemia.  His ventricular rate slowed with no particular intervention to about one hundred.  A faint, ground glass pneumonia was apparent in the left upper lobe on x-ray.  He “required” admission for treatment.

He arrived at his room with his wife and son and I arrived shortly thereafter, to find a man who was afebrile, did not appear ill, was mildly cachectic but smiled and made the occasional witty remark.  He was not able to answer questions and deferred to his wife.  He had been short of breath for a day or two, had no serious history of chronic lung or heart disease but was suffering from advanced dementia which included a failure to recognize his wife of over fifty years as his wife and a hallucinatory component in which he asserted that there was another woman in the house. Several months previous to this he had been in the hospital with pneumonia.  She said that she and her son were “trying to care for him at home” but that it was difficult because he wandered and could not sit still and his gait was shaky—they were concerned about falls.

I examined him, reviewed his laboratory data which was benign, looked at his chest x-ray and began to explain what would be done for his conditions when I sensed that something was not right.  His wife was in tears and his son stoically silent with a somewhat pained expression on his face. So I asked, “Tell me what you think of him being in the hospital.  How does he do when he is in the hospital?”

Ask and ye shall receive. His wife told me that the last time he was in the hospital for pneumonia he suffered severely from agitation and required restraints, sedation and the nocturnal presence of family.  The severity of his dementia advanced rapidly and, following discharge, he could no longer recognize her as his wife.  He had been discharged to a nursing facility where the delirium/agitation persisted and she gave me to believe that the experience of hospitalization had caused a rapid deterioration of his primary problem, dementia.

So we broadened the discussion to the family’s goals of care and expectations of medical interventions.  It became apparent that she and her son understood that in caring for him they were in an end game; they wanted to keep him out of the hospital due to its previous negative consequences.  This led to a discussion of palliative care and limiting medical interventions to those measures that preserved his sense of well-being, his comfort and his dignity.  They were in agreement and were happy to discuss what hospice services might offer them.  The hospice nurse arrived shortly thereafter.  I discharged him on an oral antibiotic for what was probably a viral pneumonia.

This is a cautionary tale, in a sense, in that it illustrates how we have evolved a medical practice that processes patients not as individual humans but as potential diagnoses, with our protocols, alerts, codes and order sets.  We do this outside the boundaries of our patients’ larger realities—their frailties, their capacity to consent, their ability to tolerate or comprehend interventions.  We are judged by our algorithmic capacity rather than our capacity to sort out a diagnosis, propose therapeutics and query our patients and families regarding their own capacities to fulfill what is directed by the algorithm.

This man was hospital intolerant and in the end stages of dementia.   How might this 90 year old man  benefit from a real “code STEMI” intervention with catheterizations, stents and subsequent delirium?  We might preserve a myocardium, for good “door to cath lab” time metrics, but offer no benefit to the patient at all.  We must listen.   We must ask.