On the first day of four days in a row, when choosing my patients I skimmed the list for the oldest patients up for grabs, per my usual habit. I ended up caring for an 81-year-old stage IV cancer with mets patient who's husband of 64 years had passed away three weeks prior. Over the four days I cared for her, I watched her go from adamantly insisting she be a full code, to begging me to knock her out and let her die. Yesterday I pulled the daughter aside and offered to refer them to palliative care. She didn't seem open to the idea. I called the primary oncology physician who told me she'd "already had this discussion with the family". I said I knew that, but today things were different and per the patient's wishes she should probably reassess. The other children came in later and spoke with the physician about their desire to comply with their mother's wishes and allow her to be comfortable in her final days.
I stepped into the conference room as all the kids started to cry. I felt an obligation to be someone strong in their presence. I fought hard to get this patient morphine from a resident, and then sat with her holding her hand and asking her to tell me about her trips to Europe, to take her mind off of the pain. The morphine didn't work and her begging to be shot and knocked out bothered me a lot. I was grateful that her family members arrived and understood that she was ready to go.
I also had a patient a few days back who came to the psych ER with panic attacks, but because of "chest pain" had to be ruled out for an MI per protocol. It was ruled out, and then some asshole of a doc on cardiology service didn't want to give him ativan, so as punishment for the patient ordered it q4 hours IM. I told him I wasn't going to give it IM when he had a working IV and could swallow pills. I gave it IV and continued to page this guy to change the order. Eventually, he did. I know what it's like to have panic attacks, and I'll be damned if I'm going to stab the patient in the ass just because some prick of a new MD thinks he's drug-seeking ativan because he's never had a panic attack before.
Two words: Patient advocacy.