Inviting Hippocrates Along on a Home Visit
MS 3: She hasn’t eaten in a week and isn’t drinking. Shouldn’t we admit her to the hospital?
Dr C: Do you think we should?
MS 3: Well… yeah. We can work her up and treat her. She seems dehydrated.
Dr C: If you notice the piece of paper on the wall over her head, you’ll see that it is a Do Not Resuscitate order based upon her previously expressed living will. She was admitted to the hospital 3 months ago for dehydration, and, after a family conference, they confirmed that she would never have wanted to receive extraordinary measures, such as a feeding tube or even intravenous fluids. The family has tried to get her to eat and drink, but she has continued to worsen. I think death is imminent.
MS 3: How can you be so sure?
Dr C: I like using the wisdom of Hippocrates. Everyone knows the rule of “First do no harm,” but he also taught that we should “observe all.” The family just told us that, when offered some fluids, she only takes a sip. For the most part, she has not been eating or drinking. Her eyes are sunken. Her mouth is dry. She is breathing rapidly and is obtunded.
MS 3: But her lungs are clear to auscultation and percussion. She’s still making urine. And her blood pressure is good at 120/80. If we admitted her to the hospital and gave her IV fluids, she would get better and live longer.
Dr C: Be careful of your words. I saw you listen to her lungs, but I didn’t see you percuss them.
MS 3: Well, no, I guess I am just in the habit of writing down that phrase.
Dr C: We’ve all made that mistake. Hippocrates also taught that we should evaluate the patient accurately. He has been called the Father of Clinical Medicine, because of this emphasis on clear and precise observation and documentation. I know you were not intending to be dishonest. I used to write PERRLA (Pupils Equal, Round, Reactive to Light, and Accommodation) in the chart without thinking about it, but I typically don’t check for accommodation. Now I document more carefully and just write PERRL. Getting back to your question: could we help her live longer if we admitted her and gave her intravenous fluids? Yes, probably. I turn to my old teacher Hippocrates here, too—he said that, when it comes to treatment, we should “assist nature.” She has expressed her wish to let nature take its course. I think making her comfortable at home would be more in line with her previous wishes.
MS 3: I am coming off the internal medicine ward at the med u, and we were pretty aggressive. We had some sick, sick people that we sent home. How can we do nothing? With everything that we now can do in medicine, I’m uncomfortable following Hippocrates on everything. He practiced more than 2,000 years ago!
Dr C: I understand. Most students know the first rule of Hippocrates, but there is so much more that some of the greatest physicians and other educators had to teach us about the art of medicine. To answer your question: Sometimes doing nothing is the hardest thing to do. To quote another of our famous teachers, Aristotle said, “It is sometimes wiser to know when not to measure things.” In this case I will ask the visiting nurse to discontinue all vital signs.
MS 3: You’ve taught me that before: only order a test if I am going to do something with the result. What else did Hippocrates say?
Dr C: The collective wisdom of Hippocrates is called the Corpus Hippocraticum, and while much of what is attributed to Hippocrates may not truly have been said by him, we still reference it as a teaching of Hippocrates. In this case, he might also add to “prognosticate when you can.”
MS 3: What do you mean?
Dr C: I mean we should let our patient, or in this case her family, know what we know. That death is near. Sometimes we underestimate our power as teachers. Did you know that the word doctor comes from the Latin docere, which means to teach? I have asked her daughter to let other family members know that Grandma will likely die within the next 1 to 2 weeks so that they may come to visit and be with her.
MS 3: We are exposed to the Hippocratic Oath but not the other sayings. I like feeling that I’m part of a long tradition.
Dr C: Most of us learn the art of medicine by working alongside more experienced physicians. But you can also learn from studying what was written about other famous teachers throughout history. Maimonides, Osler, Peabody, and Schweitzer are just some of the fascinating teachers and role models who have come before us, and who can guide us now.
MS 3: So what should we do now?
Dr C: We should do what all of these doctors would do in a case like this: care for the patient. More importantly, what do you think we should do now—admit her? If you want to, we can offer that option to the daughter, as I have in the past.
MS 3: No, I don’t want to push for admission. But I would like to talk to the patient’s daughter some more. I’d like to make sure she understands what is going on and perhaps explain to her that her mother is not in pain. The family can still offer her fluids. That may make them feel better, even if it will not likely change the outcome. I saw a box of straws at the bedside.
Dr C: Great job. You are “observing all.”
Richard Colgan, MD, University of Maryland, Author
Alec Chessman, MD, Medical University of South Carolina, Editor
- Colgan R. Advice to the young physician on the art of medicine, first edition. New York: Springer, 2010.
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