Jane T. Broxterman, MD
Requests for Single Reprints: Jane T. Broxterman, MD, University of Kansas Medical Center, 3901 Rainbow Boulevard, 4035 Delp, MS 1027, Kansas City, Kansas 66160; e-mail, email@example.com.
Broxterman J.; Miracle on 39th Street. Ann Intern Med. 2013;159:854-855. doi: 10.7326/0003-4819-159-12-201312170-00013
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Published: Ann Intern Med. 2013;159(12):854-855.
It was 2 weeks before Christmas, and I was rounding on our inpatient palliative care service for the weekend. I practice at our medical center on 39th Street as a general internist primarily in the ambulatory setting and round part-time on our palliative care team. Most new consults are for goals-of-care discussions and expertise in counseling. I had not been notified of any new consults overnight, so that morning I was surprised to see the name of one of my long-time clinic patients on our consult list.
My patient, Mr. W, was a 73-year-old man I had seen in clinic for the past several years. He enjoyed traveling across the country in his recreational vehicle, playing the guitar in his bluegrass band, spending time with family, and telling stories of the “good old days.” I felt sad and unprepared to suddenly be his palliative care doctor. On service, I certainly had seen my fair share of catastrophic events, but this felt different; I knew him.
Thomas E. Finucane
Johns Hopkins Bayview Medical Center
December 23, 2013
Goals of Palliative Care
"Miracle on 39th Street” describes the unexpected and wonderful recovery of a 73 year-old man who’d been found unconscious. His large, expanding subdural hematoma led to partial uncal herniation. To achieve standard palliative care treatment goals, “to ensure that the patient is comfortable and symptoms are well-managed,” the patient was receiving propofol and fentanyl infusions. When these were stopped, and as he recovered, he wrote “My throat hurts.” Later he “showed signs of fatigue so I restarted low-dose fentanyl so that he could rest.”
Even under the flag of Palliative Care, using propofol and fentanyl to ensure comfort and manage symptoms for a patient with a sore throat, and using fentanyl so that a fatigued patient can rest seem oddly imprecise and disproportionate.
Jane T. Broxterman, MD
University of Kansas School of Medicine
February 7, 2014
This piece was not designed to be a case report, but was a reflection on the importance of patient continuity and the physical examination. Due to the space limitations and peer-reviewed editing suggestions, specific patient related details were intentionally not explained. You are correct, when one reads the below excerpt out of context, and was not at the bedside, it can seem aggressive, and perhaps inappropriate. However, when goals of care remained uncertain (extubation with or without re-intubation, full treatment, versus full comfort, etc) in the setting of an unexpected physical examination finding, as certainly you are aware, one must proceed cautiously. Though he was aware of his surroundings, he was clearly fatigued. He is a relatively frail gentleman who had sustained a life threatening injury, and he remained intubated in the ICU. Given his less than optimal stamina, it was clear that we could not be successfully extubated at that time. Thus, a low dose narcotic drip was restarted, as it is standard protocol to provide dose appropriate sedation while mechanically ventilated.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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