You are here.

This patient isn’t usually mine, but today I’m covering for my partner in our family-practice office, so he has been slipped into my schedule.

Reading his chart, I have an ominous feeling that this visit won’t be simple.

A tall, lanky man with an air of quiet dignity, he is 88. His legs are swollen, and merely talking makes him short of breath.

He suffers from both congestive heart failure and renal failure. It’s a medical Catch-22: When one condition is treated and gets better, the other condition gets worse. His past year has been an endless cycle of medication adjustments carried out by dueling specialists and punctuated by emergency-room visits and hospitalizations.

Hemodialysis would break the medical stalemate, but my patient flatly refuses it. Given his frail health, and the discomfort and inconvenience involved, I can’t blame him.

Now his cardiologist has referred him back to us, his primary-care providers. Why send him here and not to the ER? I wonder fleetingly.

With us is his daughter, who has driven from Philadelphia, an hour away. She seems dutiful but wary, awaiting the clinical wisdom of yet another doctor.

After 30 years of practice, I know that I can’t possibly solve this man’s medical conundrum.

A cardiologist and a nephrologist haven’t been able to help him, I reflect,so how can I? I’m a family doctor, not a magician. I can send him back to the ER, and they’ll admit him to the hospital. But that will just continue the cycle… .

Still, my first instinct is to do something to improve the functioning of his heart and kidneys. I start mulling over the possibilities, knowing all the while that it’s useless to try.

Then I remember a visiting palliative-care physician’s words about caring for the fragile elderly: “We forget to ask patients what they want from their care. What are their goals?”

I pause, then look this frail, dignified man in the eye.

“What are your goals for your care?” I ask. “How can I help you?”

The patient’s desire

My intuition tells me that he, like many patients in their 80s, harbors a fund of hard-won wisdom.

He won’t ask me to fix his kidneys or his heart, I think. He’ll say something noble and poignant: “I’d like to see my great-granddaughter get married next spring,” or “Help me to live long enough so that my wife and I can celebrate our 60th wedding anniversary.”

His daughter, looking tense, also faces her father and waits.

“I would like to be able to walk without falling,” he says. “Falling is horrible.”

This catches me off guard.

That’s all?

But it makes perfect sense. With challenging medical conditions commanding his caregivers’ attention, something as simple as walking is easily overlooked.

A wonderful geriatric nurse practitioner’s words come to mind: “Our goal for younger people is to help them live long and healthy lives; our goal for older patients should be to maximize their function.”

Suddenly I feel that I may be able to help, after all.

“We can order physical therapy — and there’s no need to admit you to the hospital for that,” I suggest, unsure of how this will go over.

He smiles. His daughter sighs with relief.

“He really wants to stay at home,” she says matter-of-factly.

As new as our doctor-patient relationship is, I feel emboldened to tackle the big, unspoken question looming over us.

“I know that you’ve decided against dialysis, and I can understand your decision,” I say. “And with your heart failure getting worse, your health is unlikely to improve.”

He nods.

“We have services designed to help keep you comfortable for whatever time you have left,” I venture. “And you could stay at home.”

Again, his daughter looks relieved. And he seems … well … surprisingly fine with the plan.

I call our hospice service, arranging for a nurse to visit him later today to set up physical therapy and to begin plans to help him to stay comfortable — at home.

Back home

Although I never see him again, over the next few months I sign the order forms faxed by his hospice nurses. I speak once with his granddaughter. It’s somewhat hard on his wife to have him die at home, she says, but he’s adamant that he wants to stay there.

A faxed request for sublingual morphine (used in the terminal stages of dying) prompts me to call to check up on him.

The nurse confirms that he is near death.

I feel a twinge of misgiving: Is his family happy with the process that I set in place? Does our one brief encounter qualify me to be his primary-care provider? Should I visit them all at home?

Two days later, and two months after we first met, I fill out his death certificate.

Looking back, I reflect: He didn’t go back to the hospital, he had no more falls, and he died at home, which is what he wanted. But I wonder if his wife felt the same.

Several months later, a new name appears on my patient schedule: It’s his wife.

“My family all thought I should see you,” she explains.

She, too, is in her late 80s and frail, but independent and mentally sharp. Yes, she is grieving the loss of her husband, and she’s lost some weight. No, she isn’t depressed. Her husband died peacefully at home, and it felt like the right thing for everyone.

“He liked you,” she says.

She’s suffering from fatigue and anemia. About a year ago, a hematologist diagnosed her with myelodysplasia (a bone marrow failure, often terminal). But six months back, she stopped going for medical care.

I ask why.

“They were just doing more and more tests,” she says. “And I wasn’t getting any better.”

Now I know what to do. I look her in the eye and ask:

“What are your goals for your care, and how can I help you?”

-Mitch Kaminski

“Dear Greenhill”, a project by the Class of 2015

To educate our private high school on microaggressions, the seniors of Greenhill School made a presentation named “Dear Greenhill”, inspired by the film “Dear White People”. We each wrote down responses to microaggressions we’ve experienced in the past and read them out loud during assembly. With the help of our Director of Equity and Inclusion, we bring awareness to the fact that, while our school prides itself on diversity, students of various minorities still face prejudice at school daily, and we still have a long way to go until we can ourselves “inclusive”. 

We challenge our classmates and teachers to recognize and address microaggressions and larger systems of oppression within our community, and we charge our school to not be content with the way things are, but to embrace progress and improvement.

Autistic lack of empathy is perceived in this really moralized way, but consider that:

many autistic people demonstrate extraordinary ability to be compassionate. For example, Temple Grandin, advocating for the rights and respectful treatment of animals, who has revolutionized the process of slaughter to be less painful and distressing. She understood the feelings of animals and and their capacity to feel pain, in ways no allitistc person did (or could).

studies have shown that autistic people are actually completely capable of understanding moral concepts. Having low or no empathy (ability to read and understand people) is not equal to a lack of remorse or social responsibility. And especially not enjoying the suffering of others. Moral and empathy are not equatable. Maybe read this.

And ironically; allistic people look at autistic people and conclude we have no feelings or capacity to feel pain/hurt (so bullying, abuse, etc won’t hurt us)… because we are less inclined to openly show what we feel and think. (Not to mention our ways of expressing pain are often misunderstood). Then they say to us we are Bad, because we don’t understand what other people feel and think unless we are told. I mean?

Then there’s how often autistic people are abused, bullied and even murdered by allitistic people; we are much more likely to victims. And how often this is forgiven or excused.

Honestly, I think a lack of empathy is just as easily hurtful to the person experiencing it. It makes you exploitable and difficult for you to self-assert. It makes you easy to take advantage of or manipulate… usually by people with high social comprehension perfectly aware what they’re doing. (I’ve experienced this first hand so much).

Due to a rare genetic disorder, my father and three of my uncles are blind. So even though I’ve had sight my whole life, I know that most people’s definition of blindness misses a huge chunk of what going through life without vision is really like.

Okay despite that lead-in, Cracked actually wrote a really great article about Blindness? (Starting with MOST BLIND PEOPLE HAVE SOME VISION, GUYS, and ending with like, social model?)

My mother had her pre-natal care, and her post-miscarriage care, at Planned Parenthood.

Because it was the best place for her.  Because at the time, she had a two year old child and a bike and they were living just around that nice little sweet spot between ‘desperately poor’ and 'almost have enough to consider a savings account.'  And when you are poor, and female, and need health services, Planned Parenthood is there.

And my mother walked past the protesters, walked past the people who screamed at her about not killing her baby, about how she was a whore, and she was going to hell.  My mother, in mourning for a child that she had lost, blaming herself, hating herself for failing at this most feminine of things, walked through that, to care for herself, to get the medical care she needed.  So that someday, two years later, she could have me.

I cannot speak to the courage that must have taken.  But that path is walked by thousands of women.  Every single day.

She donated to Planned Parenthood until her death.  And she said to me, that the people who screamed at her saw her only as a vessel for a baby.  They didn’t care about her, they didn’t care about her baby, either.  They were pro-birth, not pro-life, because none of them would be there after her baby was born, to offer help and support and care. 

Tonight I decided to walk home, a further distance than I normally would. The bus wasn’t coming, the weather was nice, and I thought the exercise would feel good. I turned on my music, but kept my headphones down around my neck so that they wouldn’t impede my ability to hear what was going on around me. I stayed in fairly populated, well-lit areas. I kept my shoulders back and my chin up so that I looked confident. I put my keys in my fist so that they would be out and ready if I needed to slash or punch anyone with them. I looked around frequently to keep an eye on any changes in my surroundings. I slowed down and veered to avoid any alcoves or darkened areas where someone had the potential to be hiding. I looked out for anyone in my vicinity and made a quick judgment of how easily they could overpower me, how likely I was to outrun them. I listened hard for new footsteps. I made close note of escape routes.

Can you provide the population of people in the UK classified as half-giants? Can you provide the population of corporeal ghosts? Can you provide the population of people that are actual practitioners of witchcraft?   Can you provide the population of shapeshifters in the UK?   Can you provide the population of elves in the UK? 

I’ll wait. 

Rachel Rostad - "To JK Rowling, from Cho Chang" (CUPSI 2013 Finals)