One of the privileges of primary care is getting to know patients over time. Mr. B was a patient who brought a smile to my face whenever he called or came to see me. At 93, he lived independently, had a girlfriend, and always arrived wearing a dapper outfit with an apt remark about the news. He sent me postcards during his winters in Arizona and from family events. Last winter, while in Arizona, he had a stroke. He recovered quite well with physical and occupational therapy at home. This winter, he stayed in New York rather than travelling to Arizona to be closer to family and his medical team. We saw each other regularly, and I prided myself on contributing to the fact that he had remained spry and out of the hospital for a year following the stroke. I believe another key to his success over this time was his girlfriend, whom he visited weekly.
During mid-March, Mr. B came to see me for a “cold,” as he had several times before. Finding a benign exam, I explained social distancing and asked Mr. B to speak with his girlfriend on the phone rather than visiting due to the COVID-19 epidemic. He went anyway, and called me a few days later to report a cough.
Things started to worsen the following week, just as the COVID-19 pandemic began to spread in New York. Mr. B developed a fever. Considering the possibility his cold had developed into community acquired pneumonia, I treated him with antibiotics, which quelled the fever for a few days. We did telehealth visits, with the assistance of Mr. B’s tech-savvy daughter.
As the likelihood Mr. B had COVID-19 grew with each telehealth visit, I spoke with Mr. B and his family about potential hospitalization if his symptoms worsened. Discussing goals of care via telehealth was not something I was accustomed to as a primary care provider, but thankfully, Mr. B and his family were all on the same page. Mr. B wanted to be comfortable and to remain in his home. I brought up the idea of home hospice, as his probable COVID-19 might or might not be a life-limiting condition depending on the trajectory of the illness. Mr. B and his daughter were initially skeptical, but quickly warmed to the idea. Things progressed quickly. Papers were signed, and home nurses arrived the next day, just as Mr. B began to require oxygen and experience delirium. Again I raised the possibility of hospitalization, and again, the family resolutely declined. Two days later, his daughter, a former nurse, let me know his oxygen level was 72%. We focused on comfort and worked with the home hospice team. He died the following day, in his home.
Faced with the potential of hospitalization for a severe infection with a high pre-test probability of mechanical ventilation, a patient and his family chose home hospice...Tough conversations avoided an unwanted hospitalization, and likely, an ICU stay for mechanical ventilation.
As his primary care physician of four years, I will treasure our relationship. I miss Mr. B already. Reflecting on his end-of-life care, I take solace that Mr. B died as per his wishes in home hospice. In the midst of a global pandemic, with shortages of equipment and projected rationing of ventilators, the case seems revealing. Faced with the potential of hospitalization for a severe infection with a high pre-test probability of mechanical ventilation, a patient and his family chose home hospice. Services were set up quickly, and the patient died in line with his wishes. Tough conversations avoided an unwanted hospitalization, and likely, an ICU stay for mechanical ventilation. How many of these conversations, prior to or early on in the disease trajectory, might avoid this outcome for patients of a similar mind? As primary care physicians are redeployed to hospital care and in some cases ill themselves, who will have these conversations? How can we approach these conversations optimally and convey much needed empathy and support given the limitations of telehealth, when our training and experience has emphasized in-person conversations around goals of care? How can we encourage accessibility to telehealth for the isolated, elderly, and ill who may need these services the most? How can we preserve the patient-physician relationship as a scarce resource in this pandemic?