What matters most

     I walked into his room while looking at my notes. I quickly went through all the motions of introducing myself and my team and shook his hand. He started to say something about the food he was served but I cut him off before he wasted anymore of my time. I had a full load of patients and charts to get through for the day. I glanced down at my notes again before asking him a perfunctory question that I already knew the answer to.

Me: So Mr. G, you were just admitted last month for heart failure. What made you come back to the ER?

Him: I could not breathe. I was swelling up with fluid and I read on the internet that these could be signs of worsening heart failure. So I decided to come in to get looked at.

    The case manager assigned to our team had already informed me that he was a readmission for heart failure within 30 days of last admission, he was going to cost the hospital a lot of money and ding our ratings. Readmission are mostly due to non-compliance with treatment, I proceeded to ask him some more questions.

Me: You were feeling good before you were discharged home the last time. You must have not taken your medications like you were supposed to. 

Him: That may be true, I apologize for it. 

Me: Apologizing doesn't help. We need to make sure that you take your medications. It is extremely important to be compliant. Patients with heart failure who are not compliant with their medications have worse outcomes.

Him: What kind of outcomes?

Me: They keep getting readmitted and eventually die!

Him: I understand. The medications made me feel weak and changed the taste of food. I love eating Mexican food and since I started the medications, I don't seem to enjoy it anymore.

Me: Mr. G, that's a good thing. Mexican food is salty and eating salt is not good for patients with heart failure. Salt makes you hold onto water, causing you to swell up and feel short of breath. You were educated about that during your last hospitalization. You should have payed more attention. When was the last time you ate Mexican food?

Him: Yesterday. It was my 87th birthday. I never thought I would make it this long. My wife and I would always go out to eat at this Mexican restaurant. She died last ...

Me: You can't eat at restaurants anymore. You have to make your own food at home. Do you live by yourself? 

Him: I understand. I apologize, like I was saying, my wife died...

Me: Again, Mr. G, apologizing is not going to help. We need to come up with solutions here. Work with us, otherwise you will keep coming back to the hospital. The plan is to stop eating at restaurants, stop salt, take your medications and follow up with your doctors in clinic. Thats what you need to do if you don't want to keep getting admitted to the hospital. 

    I proceeded to increase the dose of his medications. I reviewed the medication list with the case manager to make sure I was not missing anything that would get me audited. I made a referral to the cardiology clinic and made a note to the cardiologist to perform procedures that Mr. G was due for. He was discharged home the next day  

    I forgot all about Mr. G till 3 weeks later. His name popped up on my computer, he was back in the hospital. I rolled my eyes, another readmission within 30 days, this did not look good for me. I was glad he was not admitted to my service but was accepted by my colleague. Better her than I, I thought to myself.  

    I glanced at the notes, it was the same thing all over again. He just didn't listen to my advice and didn't take his medications (surely he was still eating at his favorite Mexican restaurant. Wonder whose birthday it was this time?). Then I came upon a note from palliative care team. My colleague got palliative care team to meet with this guy. She mentioned something about him wanting to choose comfort care and hospice given his diagnosis of heart failure. 

    The palliative care note mentioned something about depression related to his wife dying from cancer last year and that he was living by himself since then. Mexican food was his favorite and one of the few pleasures that he still enjoyed. He was scheduled to undergo a procedure based on my recommendations during the last visit, but to my dismay, it was cancelled based on his discussions with the palliative care team. He did not want to undergo any life prolonging procedures. He wanted to focus on quality of life and not quantity of life.

    That procedure was known to be life prolonging for patients with heart failure. I felt this surge of frustration toward my colleague and the palliative care team. These physicians went to medical school, residency and fellowship, just like me. How can they now encourage patients to refuse life prolonging therapies and choose to do as they please? If patients refuse to follow orders and decline procedures, how will we keep them alive? Making our patients live longer lives is what matters most. 

Aneesh