I have come to think that the Fat Man was right. And Jo, possibly, was an idiot.
Explore This IssueACEP News: Vol 31 – No 09 – September 2012
Emergency physicians are being confronted with increasing numbers of geriatric patients. Now, I love my geriatric patients. They have the most interesting stories about better and harder times alike. But I sometimes wonder if they would be healthier and happier if we didn’t do everything we do for them.
Those of you who have read Samuel Shem’s classic The House of God might recognize some of these questions. For those of you who haven’t, find a copy, STAT.
In The House of God, the patients get better without the life-saving treatment from Man’s Best Hospital. Law Number One of the House of God: “GOMERs” never die.
We see those “GOMERs” every day: demented nursing home and hospice patients who don’t know their families or the day of the week. We find ourselves putting in central lines and rectal tubes and pumping on their chests because their families want them to be a “full code.”
When I was a resident, I had a patient I’ll call Frannie. It was April, and she had been there since February. No matter what I said to her family, she was always a full code. This poor lady had a trach, a Foley, a rectal tube, a gastric tube, an arterial line, and two central lines. She was 91. Whenever I spoke with her daughter regarding code status, I kept thinking, “What? Was she a bad mother?”
We don’t do all of this to people for their benefit. In many cases, we are doing it for the family members, who aren’t willing to let go yet.
At some point we need to realize we are doing things to people, instead of for them.
It’s like when in The House of God, Jo does a dementia work-up on a 95-year-old woman, including scans and a spinal tap. “I deliver medical care,” she keeps saying. “And that does not mean doing nothing.”
But I think that in some cases it does. We need to remember primum non nocere, or first do no harm.
Every day, we see the hospice cancer patient, the CHF patient, the end-stage renal patient, their families opting for every intervention possible. How barbaric is it to pound on their chests with compressions, crack their ribs, and shove tubes down their throats? Will the Foley catheter we order for the ease of the nurses condemn the patient to die of urosepsis because the nursing home staff never changes it?