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The Art of Medicine


Godfrey, Alexandra MS, PA-C

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Journal of the American Academy of PAs: March 2014 - Volume 27 - Issue 3 - p 58
doi: 10.1097/01.JAA.0000443807.20036.7a
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“Why do I need splints?” my patient challenges, flexing and extending his right elbow, then turning his left thumb upwards in a triumphant gesture. “I got no pain.”

“Well, yes,” I say. “I see your point, but your fractures will heal better if immobilized.”

My patient, a centenarian and World War II veteran, has not seen a doctor for 60 years. For over half a century, he has avoided medical offices, preferring self-medication, home remedies, and independence. No crumpled paper is in his wallet listing prescription meds and no diseases require delineation. The past decade brought him the natural deterioration of old age. His muscles wasted, his bones eroded, and his vessels took new, tortuous paths. His great-grandson did what he could: cooked meals, picked up groceries, kept up with the finances. He tried to do more: organize home care services, a visiting physician, and respite care for his great-grandfather, but the old man had proudly rejected it all, angrily tearing up the necessary paperwork. “I don't want strangers in my house. Let me die as I want,” he had grouched.

When his legs started to give out, causing him to fall and sustain significant injuries, the family had mutinied. They insisted he come to the ED. My patient acquiesced only when fractures and weakness left him unable to walk.

I look closely at the proud centenarian. The etchings of time mark his face; vaults and niches have replaced muscle and fat. A thick, yellow crust holds his right eye shut. When I pry the eye open, I see the greyish-white deposits of arcus senilis. The man's heart beats a rapid, irregularly irregular rhythm. His breathing rattles. Occasionally, he stops to cough up blood-flecked phlegm. His right elbow looks grotesque. An ecchymotic bulge over his medial humeral condyle suggests fracture. His left thumb veers too much to the right—another break? Feces sit under his fingernails, and a pungent odor hangs over him, reminding me of parking lot stairwells. The bones of his pelvis jut forward from the deep concavity of his abdomen. I wonder if he has eaten for a month. I find plastic grocery bags in his underwear. When I look at him curiously, he says defiantly, “I don't want to make a mess.”

His mind remains sharp. He knows the year and the name of the president and subtracts serial 7s from 100 with ease. His family tells me that he loves sudoku and blackjack. His dry humor suggests an IQ far above the norm.

“Why are you falling?” I ask.

“My legs won't hold my weight anymore,” he shrugs. “They're old and beat.”

The family tells me he has stopped eating altogether. When I ask him why, he says, “Food just doesn't taste good anymore, so why eat?”

I draw labs, order X-rays, a 12-lead, a urinalysis, and a lactic acid. Soon his medical history begins: “new-onset” atrial fibrillation, hyperkalemia, “acute” renal failure, hypercalcemia, UTI, pneumonia, lung mass suspicious for bronchiogenic carcinoma, fractures of the elbow and hand, and conjunctivitis. When I list these findings to my patient, he shakes his head and smiles. “I guess I am just old,” he says.

I pause.

I consider the 80-year-old woman just across the hall who is not smiling. She is on 17 meds, has 15 medical diagnoses, and has spent hours of her life waiting in hospital rooms. She is a doctor worshipper, a receiver of polypharmacy, a compliant and faithful follower of medicine. She has endured medication adverse reactions, studied the correct medical regimens, spent weeks dwelling on her diagnoses, rejected and embraced the new definitions of self and health, and become the author, then victim, of her medical narrative. The woman is drugged up and sad. This man, however, looks broken and happy. She wants everything; he wants hospice. Both are approaching the end of life, but their journeys could not be more different.

I decide maybe splints are not for everyone. In medicine, sometimes we must care enough to put aside medical ideals and textbook learning and instead focus on our patients' wishes. Splints are not for an old man who once fought and is still fighting for freedom. They are not for those who want an unfettered hand to write their own epitaph. I put the man's arm in a sling and admit him to comfort care. Who am I to deny this patient an honorable death?

© 2014 American Academy of Physician Assistants.