You Need to Know: The Big Question Doctors Forget to Ask

When you're dealing with the sick or elderly, sometimes you need to stop focusing on healing.

aol-health-big-questionPeter Oumanski for Reader's Digest

Mr. Dwyer isn’t my patient, but since I’m covering for my partner in our family practice office, he has been slipped into my schedule.

A tall, lanky man with an air of quiet dignity, Mr. Dwyer is 88. His legs are swollen, and merely talking makes him short of breath. He suffers from congestive heart failure and renal failure, a medical Catch-22: When one condition is treated and gets better, the other gets worse. His past year has been an endless cycle of medication adjustments from dueling specialists, punctuated by emergency room visits and hospitalizations.

With us is Mr. Dwyer’s daughter, Karen, who has driven from Philadelphia, an hour away. She seems dutiful but wary, awaiting the clinical wisdom of yet another doctor.

After 30 years of practice, I know that I can’t possibly solve Mr. Dwyer’s medical conundrum. Still, my first instinct is to improve the functioning of his heart and kidneys. Then I remember a visiting palliative-care physician’s words about caring for the fragile elderly: “We forget to ask patients what they want from their care. What are their goals?”

I pause, then look Mr. Dwyer in the eye. “What are your goals for your care?” I ask. “How can I help you?”

My intuition tells me that Mr. Dwyer will say something poignant: “I’d like to see my great-granddaughter get married next spring” or “Help me live long enough so that my wife and I can celebrate our 60th wedding anniversary.”

“I would like to be able to walk without falling,” Mr. Dwyer says.

This catches me off guard. That’s all? Suddenly I feel that I may be able to help after all.

“We can order physical therapy—and there’s no need to admit you to the hospital for that,” I suggest, unsure of how this will go over.

[pullquote] We forget to ask patients what they want from their care. What are their goals? [/pullquote]

Mr. Dwyer smiles. And Karen sighs with relief. “He really wants to stay at home,” she says matter-of-factly.

As new as our doctor-patient relationship is, I feel emboldened to tackle the big, unspoken question looming over us. “Mr. Dwyer, I know that you’ve decided against dialysis,” I say. “And with your heart failure getting worse, your health is unlikely to improve.”

He nods.

“We have services designed to help keep you comfortable for the time you have left,” I venture. “And you could stay at home.”

Again Karen looks relieved. And Mr. Dwyer seems fine with the plan.

Although I never see Mr. Dwyer again, over the next few months, I sign the order forms faxed by his hospice nurses. I speak once with his granddaughter. It’s somewhat hard on Mr. Dwyer’s wife to watch him decline at home, she says, but he’s adamant that he wants to stay there.

A request for sublingual morphine (used during the terminal stages of dying) prompts me to call to check up on Mr. Dwyer. I learned that he hadn’t had any more falls. Two days later, I fill out his death certificate.

Several months later, a new name appears on my patient schedule: Ellen Dwyer.

She, too, is in her late 80s and frail, but she’s mentally sharp. About a year ago, a hematologist diagnosed her with myelodysplasia (a bone marrow failure, often terminal). But six months back, Mrs. Dwyer stopped going for medical care.

I ask why.

“They were doing tests,” she says. “And I wasn’t getting better.”

Now I know what to do. I look her in the eye and ask, “Mrs. Dwyer, what are your goals for your care, and how can I help you?”

Read more: A Fascinating Look at How Doctors Choose to Die

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Originally Published in Reader's Digest

Family physician Mitch Kaminski, MD, is the chief clinical officer for the Delaware Valley Accountable Care Organization.