by Lydia S. Dugdale, MD
February 1, 2013
I glanced at the chart. New patient, female, age 72.
I have adopted the practice with new patients of quickly scanning the medication list before opening the door to greet them. In the old days patients hand wrote their medications on a paper intake form prior to the office visit. Now I click the “medications” tab in the electronic health record to review the data already entered.
A medication list can tell a doctor a lot about a patient. One glance and I know immediately what active health problems a person has, what risk factors she might have for heart disease or stroke, whether I should worry about lung cancer, whether our interaction might be complicated by mental illness, and how quickly I should move through any aspect of the office visit.
Christina Cook (name changed) recorded no medications on her form.Great! I thought. An opportunity actually to talk with my patient! I wasn’t very far into my primary care career when I realized that medical complexity is inversely proportional to how well I feel I know a person at the end of our first office visit. Sure, I see patients with complex medical problems more frequently, and over time that does amount to a greater opportunity to build relationships. But such visits typically center around managing medicines, ordering tests, and reviewing the recommendations of the specialists. At least as far as the new patient visit goes, the less complicated the patient, the more I come away with a sense of who she is.
I knocked and opened the door. Ms. Cook sat upright, with a smile on her face. Clad in a sophisticated black, she was true to form for a certain type of New Yorker. She kept an apartment in “the City” and a home in Connecticut. She read the Times and held season tickets to the opera. She was a widow but far from lonely. She had borderline blood pressure which she managed through the salt substitute Mrs. Dash and a daily three-mile walk. Though her cholesterol was probably deserving of a statin, she committed to a life of morning oatmeal: “I will discipline myself not to have to take a pill. I will learn to like that stuff.” And she cut back on red meat to once a month or less.
At some point during the visit, she asked if I would like a copy of her living will. Taking it, I asked casually, “Can you summarize it for me?” I ask this question for a couple of reasons. The first is that I typically don’t have time during the office visit to read the document in its entirety; patients can explain quite quickly if they “don’t want to live on machines if there is no hope.” Also, I like to confirm that patients understand what they have signed. Though far from the norm, I have met some people who have signed living wills that they don’t really understand.
Ms Cook’s response surprised me. She never wanted cardiac resuscitation or mechanical ventilation. “Ever!” she declared. She went on: “Look, I’ve watched friends die hooked up to machines they didn’t want. Besides, my niece and nephews are doctors, and I’ve heard their stories for years. I know that life support can keep me alive, but I’ve lived a long and healthy life. If something happened to me now, I’m okay with dying. Just let me go! And don’t prolong my suffering!” More