Saturday, June 27, 2015

Reconcilable differences.

During med reconciliation with a patient recently

"You're taking the pills in this bottle?"

"That bottle there?" The Grady elder picked it up and studied it for a few beats. "Yes, ma'am, so this bottle here. . .I teks one pill with my breakfast and one with my supper. Every day."

"Hmmm. It looks like you have a lot of different pills mixed up in here together. Is that on purpose?" I know that sometimes people do all sorts of things for convenience. I didn't want to assume anything.

"Well. I don't see so good so I jest know which bottle is the one time a day ones and what bottle the two time ones."

"So this one, you just open up and take out one in the morning and one at supper, correct?"



And you know?  I have no idea how those pills got mixed up like that. This kind of thing--that is, this exact thing--is not unusual for us to see at all. And you know what else? It's easy to look at this medication mashup and generalize it to his life--and then make a sweeping statement about his need for a nursing home ASAP. Or to, at least, push to make sure he isn't able to live alone. I get that it seems like a no-brainer when you see something as worrisome as this and then try to wrap your brain around someone taking a random assortment of cholesterol, antihypertensive, and memory pills all willy nilly.


Let the record show. This man lived alone. He was dressed and groomed appropriately and had taken public transportation to the hospital (no easy feat in downtown Atlanta.) Every day he cooks for himself, cleans for himself, does for himself and, for the most part, seems to get on just fine. He does. And has. For more years than most of his doctors have been alive.


And see, this? This is one of the hard things we navigate in patient care, particularly when it involves our geriatric population. The lumpy bedspread that the patient can't quite smooth out on their own any more. The one that requires a little help to lay flat but that isn't to the point of needing to find new linens altogether.

Does this even make sense? Sigh. 

Okay. So check it: This sweet man, this dear, dear elder needed somebody to--as the southerners say--"see about him." And he didn't have that. He'd outlived or out-healthed a lot of his family members. And a lot of the other ones had lives and families and he didn't want to be a bother.


Yeah man. This man needed somebody to see about him. To come by and check in and make sure things like this were okay. He wasn't significantly cognitively impaired or visually disabled that he couldn't get along. He did have a very limited education and admitted to being uncomfortable with most reading. But he'd worked for nearly his whole life and had managed his life quite fine. Taking him out of his home--the one that he built and paid for--is way more than a notion. Way, way more.

Fortunately, at Grady we have a lot of things we can offer someone like this patient. Some of it simple, some less so but all mostly doable and reasonable options to allow him to both remain safe and in his home at the same time.


Do I sometimes facilitate getting people into nursing care facilities? Definitely. But not without stopping what I'm doing and really, truly thinking about it. I reflect on the magnanimity of it and how it will make the patient feel. Will they be sad? Happy? Lonely? Scared? Will they feel robbed of dignity? Betrayed? Relieved? Or will they be none of these things?

A lot of folks are completely okay with nursing home placement. Others not so much. And a lot of times the patient doesn't seem to fully grasp what is happening one way or the other.

But I think about them, too.

I guess what I'm saying is that there are so many people who are in, what I believe, is this limbo space. The one where they can live independently just fine if somebody just sees about them regularly. Checks to make sure area rugs aren't heaped up and creating a fall risk or taking a box off of the porch. Runs to the store for them or throws a few old things out from the fridge. Resets whatever got unset when the electricity blinked and puts new batteries in the remote controls. And who asks about the pills and, if they can, does things like arrange them in daily pill containers and throws out the ones that the doctor either discontinued or changed.

And if that person or those people exist, I try to find them. And talk to them. Before jumping to nursing home placement or moving them out of their home to live with someone else. I talk to our pharmacists and social workers and nurses, too. We explore who their support is, like, if they have a church home or some other people out there who really care but who just didn't know. And who would help with something like reconciling medications or pulling the garbage cans to the curb and back if someone asked. Or just slowed them down long enough to think about it.

Moving too fast to notice doesn't mean folks don't care. I mean, not always it doesn't. In fact, many times it doesn't.

Sigh. I'm rambling. I know.

Look. I pray to grow old in this life. There is much that I want to do and see and experience and I think having the wisdom of an elder will make some of those things just that much more awesome. It is my wish to keep my wits about me and my ability to do things on my own indefinitely. But what I know for sure is that, over time, that latter part can hover somewhere between very possible and impossible. I guess what I'm saying is that when that time comes,  I hope someone steps in see about me and advocate for me, too.

Oh, and before someone misunderstands this as me being anti-nursing home, please recognize that nothing could be further from the truth. My point is that function is a spectrum. I'm learning to consider that more. Sometimes there are reasonable work arounds. And sometimes there aren't.

Yeah. Sometimes there just aren't.

But this time? There were some things that we could do. And so we did them. We did. 


Happy Saturday. And shout out to the social workers, the family members, the neighbors and the community people out there who see about our elders. You make a difference. You do.

Now playing on my mental iPod. . . .


  1. As I am in my sixties now, I think about this a LOT. As much as I would like to think my children would want to "see about me," I also hate to think they'll be burdened with this.
    It's hard, Sister Doctor. In a way, I wish humans had a cut-off switch so that when we're not able to do for ourselves, we could just...go.
    Unfortunately that's not the case. I honestly think I'd rather my body went before my mind.
    Again- we don't get to choose.

  2. Great post (as always). Have you read Atul Gawande's book Being Mortal? This is one of the issues that he addresses; it's a very worthwhile read.

  3. Thank you for this. Coming from a doctor, especially, this means a lot. I have found that function is a spectrum and one that fluctuates considerably depending on acute illness, nutrition, socialization or mood. My mom was diagnosed with severe dementia and was dosed for 3 years with Ebixa. When I got tired of pulling her face out of her soup I got proactive and took her off her Ebixa, her oxycontin, her statins and a bunch of other scrips that she no longer needed or shouldn't have been on in the first place. She now suffers from intermittent short term memory loss and is enjoying life. She goes out nearly every day, goes to church every Sunday and is hoping to get the all clear soon to travel. A little "seeing about" goes a long way.


  4. Awesome post Dr. Manning. Does Grady have something similar to community health workers (CHW)? I work at Penn and this situation is one in which the patient would be assigned a CHW that would step in and "see about him." It's an awesome model because CHW usually come from the same neighborhood as the patients, same race and culture, and are able to monitor/ check in on this high risk patients and their home life. It's good stuff. Here's more info on it:

  5. I love the news that knowledge because it can better educate


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