The traditional medical note follows the SOAP format: Subjective, Objective, Assessment, Plan. This piece uses the O and A portion as a frame to explore a cost-benefit analysis with a complex patient and the place of paternalism in medicine.
Some details have been changed for privacy’s sake. Nothing, however, is exaggerated.
Hx: COPD, HTN, CHF, AFib, PE, DVT, NPH, SCBCL, CNS lymphoma, subarachnoid hemorrhage, severe persistent asthma
New Dx: T2DM (type 2 diabetes mellitus)
Fasting glucose 196 (H)
BP: 140/80, HR 107, SpO2 93%
Exam: scattered rhonchi over all lung fields, crackles at lower bases, 3+ pitting edema b/l. Cranial shunt scar mostly healed.
I’ve seen this guy before. Lovely dude. 85 years old, barber (still barbering), down-to-earth, shades like P Funk, fingers like mortadella. His wife, too — cat-eye glasses, black bag, ready laugh, pity and condescension and love encased in a tall package. She towers over the shrunken, swollen ball of scars and adipose in the wheelchair next to her.
Last time he was just getting over the shunting surgery. His brain was coming back online, his wife said his memory was improving. This time, he feels much better, but the years of acute problem after acute problem have shunted our attention from his chronic ailments. Now he has T2DM, perhaps a minor addition exacerbated by the constant prednisone.
It’s impossible for me to know what led to what. Bad luck, poor choices, and a great attitude: a long life of pasta and beer cooked up with joviality and kindness. There’s an unfair stereotyping conflict in my mind: hardasses with rigid focuses on themselves and their spinach versus sweet old folks doublefisting pastries and happiness. Of course health and wellness are not mutually exclusive, but the cultural forces continue to battle each other fiercely: If you’re fat you’re lazy, if you’re fit you’re a douchebag. Love my curves, love my health. Body positive, health conscious.
Back to this dude: tons of health problems (tons), but he’s 85 and happy. No doubt that relationships and compassion and luck have kept him going this long, no doubt that at least a portion of his pain is self-inflicted.
So what to do? Uncontrolled diabetes in a person with all this other junk can easily lead to amputations, blindness, badness untold. Controlling diabetes is a pain in the ass (sometimes literally, depending on choice of injection site). Can we get happy together? Lifestyle change is hard even for a 35-year old who has decades of saved and improved life to look forward to. How can I comfort this 85-year old patient? How can I motivate him? Should I? What kind of life extension and quality of life improvement can we reasonably expect, even if he were to do everything right? “Comorbidity” is an absurdly inadequate descriptor for the complexity in this case.
The other thing, the killer thing, is that he wants to be taken care of. He told us repeatedly that he wants to be told he’s ok, and told what to do. He wants the paternalistic model we’ve been taught to kick in the proper place. Paul said he “became all things to all men,” the Buddha had his upaya, “expedient or skilful means:” their brilliance was in their ability to morph to fit the needs of the person. But I’m neither Paul nor Buddha. I’m pretty good at collaborating. I’m awful at commanding. How to best meet the needs of this person in front of me, who wants a command?