Dr. Rousseau is associate professor, General Internal Medicine and Geriatrics, and medical director, Palliative and Supportive Care, Medical University of South Carolina, Charleston, South Carolina; e-mail: firstname.lastname@example.org.
“This guy’s a dump.”
So began the resident’s presentation on Mr. Jones, a 65-year-old alcoholic with hepatitis C, hepatic encephalopathy, and recently diagnosed hepatocellular carcinoma.
“He should have been admitted to medicine, but they were full. We got dumped on. This is his third admission this month. He’s a frequent flier, a noncompliant alcoholic, always comes in with altered mental status. And he’s not getting any chemotherapy, so why did we have to admit him?”
The resident looked frazzled. He was outwardly burdened by an oncology service of very sick and complicated patients and a systemic urgency to discharge as soon as possible. Like many physicians when hurried and overwhelmed, he felt resentful. I should have asked if he realized what he had just said and used it as a teaching moment on the value of the person and the disease. I should have emphasized that we see the person as well as the disease—or at least we should. It was clearly a time for self-reflection and questions about why we used the word “dumped”—burnout, poor team dynamics, workload issues, or personal matters. But I did not. For that, I am guilty. I failed as a mentor—I condoned the use of the word “dumped.”
But a picture of Mr. Jones began to emerge, at least in my mind. No one really knew this man—his home, his life, his family—and appropriate discharge planning had failed to include the burdens of his social environment. But when you are labeled noncompliant or a problem patient and you have had several admissions, you are relegated to the periphery of priority. Not purposefully, but almost reflexively. You become a dump or, at best, a problem patient—forever.
I entered Mr. Jones’ room. He looked much older than 65. His body leaned to the right as he sat in bed, his right elbow providing crutch-like support. His skin was bruised and yellowed, and his nasal cannula rested atop his head. His belly was pregnant with ascites, and a catheter snaked from his bladder—he looked like a balloon tethered with ropes. He looked sick. He was sick.
I explained what I do and why I was there, then I listened to his story. He lived alone in a small, low-income apartment, was divorced and estranged from two sons. He was a carpenter, but on permanent disability because of a work-related injury. He admitted that he spent his monthly check on alcohol to combat loneliness and depression, and now, the fear of a terminal illness, but he did not see anything wrong with that.
“Who am I hurting?” he asked. “I don’t wanna die, but I know I am—the juice takes my mind off that.” He was scared. I asked about his medications, why he didn’t take them.
“I can’t afford ’em, doc. Yeah, I buy the beer, but it’s cheaper than the pills. And from where I’m sittin’, Miller and Budweiser do just as good a job as any pill.”
He paused, then spoke again: “Doc, I’d just rather be at home with my beer, just let me do that. I’m gonna die, just let me go home.”
“Why do you keep coming to the hospital if you want to stay home?” I asked.
“My neighbors keep calling the fire department. They bring me.”
We talked, and I sold him on the benefits of hospice as a way to keep him at home, comfortable, and have another set of eyes look in on him. He liked the idea, but he did not like the idea of not drinking, and at this point, did it really matter if he drank?
After convincing a hospice to enroll Mr. Jones in spite of his alcohol use, he went home and never returned to the hospital. He drank his beer, but I am told he was not belligerent or noncompliant; in fact, one nurse described him as a model patient, albeit one who really loved his beer.
Then he abruptly declined and transitioned to inpatient hospice and, within a day, died a comfortable and dignified death, surrounded by people whom he did not know, yet who cared about him, his story, and his value as a person.
Author’s Note: The name in this essay has been changed to protect the identity of the patient.