Ode to the Caregivers, the unsung heros

I was ashamed. After I had been whining about a page last night disrupting my sleep, I met a most amazing woman. I made a house call to see a bedbound lady this morning, Mrs. D. She has been essentially non-responsive with end stage dementia for almost 4 years. And her daughter-in-law, Denise, has been caring for her at home as they say, 24-7. Because Mrs. D is completely paralyzed, she is at high risk of developing bed sores. But for 4 years in Denise’s care, she has not had one bed sore. This could ONLY be achieved because every 2 hours day and night Denise turns Mrs. D, changes her diaper and massages her skin. EVERY 2 hours for the last 4 years. That is 17, 480 times! (Ok, maybe her husband and teenage kids have helped a few times a week, so maybe she has only done it 16,000 times.) That’s just one of the many acts of caregiving she fulfills!

The dedication to perform the physically exhausting and repetitive tasks involved in this level of caregiving is clearly the outward expression of an incredibly deep love and compassion. Denise’s husband is thankful but she doesn’t get any thanks or any response really from the patient or the patient’s other children. Don’t all of us deep down dream about being loved that unconditionally?  WOW!

The crazy thing is, there are hundreds and thousands of caregivers like Denise. They are invisible to most of the world as they are confined to their homes full time or working in institutions like nursing homes that most people try to avoid at all costs. Just as you might not think about the components of your car that keep it functioning, you likely don’t recognize the importance of these caregivers—they may not be very visible but they really are the cogs in the engine of love and life. 

Inspiration from Old Hippocrates

"Cure sometimes, treat often, care always."

I've seen this quote attributed to the Father of Medicine and to Dr. Edward Trudeau (1800s), but I suppose it doesn't matter who said it.  

What matters is that it is a poignant reminder that despite medical advances over years, decades, centuries . . . our calling as physicians remains the same.

There are still so few diseases that we cure.  Perhaps we prescribe antibiotics that get our patients over infections, but much of our time is devoted to corralling chronic diseases, some more successfully than others.

When it comes to geriatrics, in particular, our patients face many conditions that march along becoming more debilitating over time - dementia, heart failure, Parkinson's disease, to name a few. 
Sometimes it makes one feel powerless when patients come to us seeking to "get better."  However, that's when I remember the last two words of the phrase.  Comfort always.  When we put science aside and relate to our patients on a human level, we are always doing them a service.  And perhaps we're doing ourselves as service, as well.   

Hello Sweetie

"Hello sweetie." 

The common phrase that I'd heard since I was a child and the typical greeting that she gave to anyone that came by to see her.  No one noticed that she couldn't remember anyone's names.  It wasn't until we were looking at pictures one day and she said, "Well, that's a good-looking family. Who's that?"  "That's our family, and that's you right there in front," we told her.

As time went by things became more apparent.  The pots left on the stove.  The laundry started but not finished.  The repeated questions a few minutes apart.  I remember shortly before she moved into the long term care facility, I went to visit her with my brother.  She asked me how my grandparents were (her sister and brother-in-law who had passed away about 8 years prior).  I was only 15 or 16 at the time, and I remember the sadness in her eyes as we reminded her that my grandparents had passed.  "Oh yeah, I remember," she said.  A few minutes later, she again asked about my grandparents.  Knowing the distress it caused before, we simply smiled, and said, "they're doing just fine."  "Oh, that's great sweetie," she said.       

Over the next several years, she had a slow and steady decline.  I was working at the hospital when she was admitted nearing her end stages.  She wasn't eating or drinking well, and she was having recurrent episodes of dehydration and infections.  She didn't even know her sisters at the time.  I remember walking into her room as a lab assistant to see her smiling face and hearing, "hello, sweetie", and even though I knew she didn't know me, for a short period of time, she was still the same aunt I had known since childhood.  Thankfully for us, dementia never took that away from her.  

- Adam Merando, MD

Why in the world does my patient need a Geriatrician?

Prior to my rotation on Geriatrics I always asked myself, “why would I send my patient to a Geriatrician when almost all of my patient’s in my Internal Medicine Clinic meet the age criteria as a geriatrics patient?” This answer was quickly answered within one week on this rotation. I soon realized how easily patients can hide their dementia with jokes, laughter, wittiness or even compliments. I have performed mini-mental status exams in the past, but most of the time it was on patient’s that clearly had dementia. When I performed these tests on patients that appeared to have “normal cognition” I was amazed how subtle dementia can be. It was then that I realized that some of these patients are not getting the time and attention they deserve.

One thing that really stuck with me after this rotation is the realization that a full Geriatrics H&P will tell you more about that that patient than three, or even four, Internal Medicine clinic visits will. I had one patient in my regularly scheduled Internal Medicine Clinic that I had seen about three times in the past. His vitals and labs have always looked good compared to any of my other patients. On the surface there were no signs of dementia or even mild cognitive impairment.

However, I decided to ask about ADL’s and IADL’s and I performed a mini-mental status exam on this patient. At that point I realized that this patient had subtle, mild dementia and was requiring a lot more help at home than I had previously expected. This made me reevaluate this patient’s medication list. I asked myself, “do I really need his blood pressure at 120/80 while on HCTZ? What if he becomes orthostatic and he falls and breaks a hip? Does he really need his A1c at 5.7 while on Glipizide and Metformin and risk him having a hypoglycemic event? What is wrong with a goal of 7 or even a little bit higher for his age?”

At that point I decided to really take a look at his medication list and remove those meds that can actually do him more harm in the short run than good in the long run. I was well aware at this point what the life expectancy of a patient is who is 85 years old and I was also aware of the mortality rate of patient with a broken hip after 2 years. I did not want to contribute to this patient’s possible future suffering due to trying to overly correct lab values and vitals. Sometimes less is more.

I have always been trained to have a certain blood pressure and certain A1c and as long as it falls within those ranges then I’m doing my patient a great service. But this is not the case in the elderly population, especially those with dementia which will undoubtedly progress, as the statistics show. So thanks to this rotation I really feel that this new insight and way of thinking will help me as a Hospitalist when I’m caring for my patient and when I’m getting ready to discharge them home or to a facility.

- Michael Gutierrez, MD

California Memories

A small moment can evoke the most vibrant memory

I just left the most amazing conference and I am inspired. Inspired to teach, inspired to learn, inspired to create, and even inspired to live. You might ask how attending a conference with a bunch of academic geriatricians could even come close to evoking this many positive emotions... but it was only the conference. 

This meeting was on the beach in Coronado. It's true, I love the beach. I even love the fact that I have to wear tons of clothing and sunblock to avoid a burn. It's the waves and the serenity. But more than that, this particular beach made me think of my grandparents. 

Pa is still at home in Kansas enjoying his endless and putrid cigars, but he really isn't able to travel easily and certainly not by himself. He and Grandma loved to travel, and travel they did. That is, until her stroke at age 59 left her paralyzed and functionally dependent. 

I imagine that they traveled well prior to that time -- Grandma was the type that got dressed everyday and didn't leave the house without lipstick, carried a fancy purse, and faced the world. And Pa, well he just wanted her to be happy. They would have loved this place together with it never ending beauty, delicious food, and places to sit down and smoke.

I passed a man smoking a pipe on the beach yesterday. Normally, I would have been irritated by the smoke and hurried past. Instead, I stopped directly in the smoke's path and inhaled deeply, loving every morsel of the Cherry Cavendish... or whatever it was. And then I called Pa.

And found out that he and Grandma had been to Coronado... and loved it. 

Perspective is everything

In my white coat
Talking to a family
About their options
     for discharge, for goals, for support at home
Defining my expectations
Directing them down a path

In my white coat
Reviewing the med list
Stopping and starting drugs
    without a backward glance
Meeting criteria and guidelines
Documenting reasons for not

In my white coat
Making medical decisions
Based on my understanding
     of the patient's understanding, the family's
Coordinating other providers
Discussing with social services

How different when you shed the white coat

In my grey sweatshirt
Listening to a doctor
About my loved ones options
   for discharge, for goals, for support at home
Hearing their expecations
Disbelieving of the path

In my grey sweatshirt
Hearing the med list
And it's many, many changes
   trying to remember, to understand
Ignoring criteria and guidelines
Stopping the intolerable side effects

In my grey sweatshirt
Making medical decisions
Based on my understanding
   of the provider, of the person, of my family
Coordinating care because
As family and provider both
     I know more than I want to.

PLACEMENT--Arghh!!

I have a love-hate relationship with euphemisms. There are times that it is nice (and even funny) to allude to something without having to say that ugly word, right? It took me a while to accept the euphemisms related to dying. But now I understand that as long as we say "dying" once clearly, euphemisms can soften the blow of a harsh reality.

However, the use of "placement," when referring to a nursing home move disturbs me. It feels cold and in a disingenuous way, makes it seem as though this is happening outside of any one's control and maybe is even a special honor--"Her Placement." Perhaps this language perpetuates the negative perception of nursing homes, too. Of course, moving to a nursing home is emotionally difficult for all involved BUT as hard as it is to face, active supportive language such as -- "It looks like it is time to move your family member to a nursing home" might in fact be more loving and responsible than "she will be placed."