Mr. B is excited to go home today. This past month has been difficult for him. He was admitted to the hospital with pneumonia that turned into sepsis. Later it became clear that the infection resulted from a newly diagnosed lung cancer that had blocked his airways. Initially on a mechanical ventilator, he could not talk, and then when delirium set in he was very confused.
With guidance from medical ethics, we turned to his family to be his surrogate decision-maker. We had gently explained that the cancer was the true cause of the disaster and that it had spread to other parts of the body; there was no cure. When we tested him to see if he could breathe without the ventilator, he barely passed the test; there was a high risk that he would not continue to breathe long on his own. His family said that he would not want to be hooked up to machines. We agreed to “liberate” him from the machine and bring him to the palliative care unit.
The next few days he mostly slept. But eventually, he awoke, recognized his family, asked for some fried catfish, put on his football cap and watched the big game. He stood at the side of the bed and made a few steps only to be racked by cough. I called my favorite radiation oncologist who agreed to give Mr. B a week’s worth of treatments to the mass compressing the airway even though we might normally think he was too weak for treatment.
Rail thin, he sat on the edge of his bed. I sat next to him and reviewed with him his diagnosis and the plan to go home with hospice. He told me he knew he had cancer even before the doctors told him. Many of his friends who fought with him in Vietnam had died from this disease. He knew this was cancer when his cough changed, lost weight and found streaks of blood in his spit.
His wife has gone home to make ready his arrival. She made up the hospital bed, cleaned the house and cooked. I think there was a party planned for the night. I discussed with him that most of the medications he had taken before he got sick would no longer be needed. I would order only the medications needed for his comfort. He stopped me for a moment and said that some of these medications were very important to both he and his wife. I said I would choose carefully and if something was needed to be started back later, I could.
The computer prompted me to do the medication reconciliation as to what would be the medications he would take at home. As I went through them I thought, no need for this vitamin pill, this medication for elevated cholesterol and another for diabetes and hypertension can be all discontinued. Then the computer presents the order for a medication that has the instructions “1 tablet 1 hour before sexual activity”. I chose “accept” and made sure that it was at the pharmacy window, along with his pain medications when he was ready to go home.