Friday, January 9, 2009

The Instincts to Trust Are Usually the Patient’s


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Not long ago, I took care of an elderly man with congestive heart failure. A few days into his stay in the hospital, he told me he was not going to make it out alive. “I am going to die here,” he whispered, as if letting me in on a secret.

I tried to reassure him: on the scale of disease I normally treat, his case was relatively mild. But then he became sicker.

His bloated legs dripped fluid, soaking his bed sheets and puddling on the tile floor. His blood pressure dropped. He became delirious. I was perplexed by the precipitous downturn. What did my patient know that I did not?

After several days of keeping round-the-clock vigil in the intensive care unit, his wife of nearly 50 years could no longer bear his suffering and requested hospice care. A few hours before he died, groggy from morphine, he managed to summon a few moments of lucidity. Gripping his wife’s hand, he said to her, “You’re doing the right thing.”

Every day in medicine there are examples of patients who know they are about to die, even if no one else does. They often have a feeling of impending doom before a catastrophic event like a heart attack or a fatal infection, and though doctors don’t know how to explain it, most of us take it seriously.

When we talk about instinct in medicine, we usually talk about expert clinicians grasping diagnoses in ways that seem to defy analytical explanation. These doctors appear to know almost intuitively which data to focus on and which to ignore. Of course, their decision-making is based on experience and deductive reasoning (and perhaps on evidence, too), yet it seems almost mystical.

I will never forget the time in medical school when we presented a baffling case to the chief of medicine. He made a diagnosis of primary pulmonary hypertension within seconds, on the basis (he claimed) of the loudness of the second heart sound, an incredible feat of observation and logical synthesis.

This sort of diagnostic intuition is becoming rare in the current era of technological medicine. Patients today often receive a battery of tests even before a physician examines them. The results, usually expressed in numbers that give a misleading impression of absolute precision, tend to lull doctors into a sort of laziness that has atrophied instinct.

On the other hand, doctors’ prognostic instincts have always been poor. In my work as a critical care cardiologist, I am often asked to predict how long someone is going to live. I know how useful such projections can be to patients and their families, but I rarely, if ever, venture a guess because they are so often inaccurate. (I am usually too optimistic.)

So it amazes and baffles me when patients have a sixth sense about their own deaths. Last year, my team cared for a woman who told us calmly on morning rounds that she had a feeling she was going to die that day.

A few hours later she complained of belly pain, and when a tube was inserted through her nose and into her stomach, old digested blood — “coffee ground” secretions — came up. Her blood count plummeted, and within a few hours she had spiraled into shock and multiple organ failure, even before we could get a CAT scan to see what was going on. It was totally unexpected, one of the most rapid noncardiac deaths I have ever witnessed.

I don’t know how my patient was seemingly able to predict her own demise. Perhaps high levels of circulating adrenaline caused a reaction similar to a panic attack; I don’t know. But I have learned over time to take such intuitions very seriously.

Sometimes, morbid instincts derive from other sources. In 2007, The New England Journal of Medicine had the story of a cat named Oscar who lives in a nursing home in Providence, R.I., and seems to have an uncanny sense for when elderly residents are about to die.

He goes to their rooms, curls up beside them — even those residents for whom he has previously shown little interest — and purrs. Staff members at the facility have learned that this is a telltale sign of impending death, having witnessed this behavior in the deaths of at least 25 patients. “This is a cat that knows death,” one doctor said. “His instincts that a patient is about to die are often more acute than the instincts of medical professionals.”

No doubt there are more such animals. But I have learned that the best instincts in medicine derive from the patients themselves. Their intuitions about their own health may be denigrated by doctors. But we must learn to pay attention to them. As my patients have taught me, they often hold the vital clue.

Sandeep Jauhar is a cardiologist on Long Island and the author of the recent memoir “Intern: A Doctor’s Initiation.”

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