Assumptions

2014
Pereles, Lauretta

“Can you take a 1st year resident for some nursing home experience?’” I mentally flip through my morning: there was an admission conference, a couple of patients with acute illness and an annual assessment. While the trend is to move away from annual physicals in the office, in the nursing home it is the rule. It would be a good assessment of the resident’s physical exam skills.

“Have the resident meet me at the Second Cup on Wednesday morning at 8 am. I’ll be sitting across from the cash register.”

 I looked at my watch: 8:15 and no resident. I finished my coffee and surveyed the shop.  Several young people had been to the cash, but none had approached me.  Finally at 8:20 a smartly dressed young man can up. “Are you Dr. P., by chance?” he asked tentatively.

“Kim Lee?” asked.

“Yes,” his face brightened.

“I'm Dr. P,” I said and stood up.

 “Oh,” he said with a flustered look. “I expected to meet a man. All the other Nursing home preceptors have been male.” He dropped his eyes.

“That’s probably true, but I haven’t become male yet,” I smiled and added, “I was expecting a female resident. Let’s go then.”

At the end of the morning we went to do a physical on Mrs. Bass, a patient with dementia. Often these patients are suspicious and combative so I accompanied the resident.

Mrs. Bass’s room was sparse, just a bed and tired Lazy Boy rocker.  A faint smell of urine hung in the air.  She was perched on the edge of the bed fidgeting with her flimsy gown.

“Mrs. Bass, Do you remember me? “ She looked blank. “I am your doctor and this is Dr. Lee. We are going to check your heart and a few other things? Okay? “

She nodded but moved away.  “Let’s start with your blood pressure,” I said.   The resident had a gentle touch and the exam progressed with minimal resistance.

“Should we examine her breasts as well?” he asked.  Mrs. Bass clutched her gown closer to her chest.

“Yes,” I said.  I held her hand for reassurance.

 “Oh there is a lump here,” the resident exclaimed and looked up at me.

He moved to the side. Sure enough, there was a lump 2-3 cm in size with one node in the axilla.

“Mrs. Bass, Dr. Lee has found a lump in your breast, were you aware of it?” I asked.   

She shook her head. “I don’t have a lump,” she said and crossed her arms over her chest.

“But you do,” said the Resident.

“No I don’t,” she shouted.

“Okay,” I said, “we’re finished here. Thank you.” I motioned the resident out of the room.

“But….” he frowned.

“There is no point in arguing with her. She has dementia and is not competent to make her own decisions,” I said. “We have to speak to her daughter in Manitoba.  She is the designated decision maker. 

“But she is not that demented, shouldn’t she be involved in the decision making?” he asked.

 “Yes, of course, but she is more demented than she appears,” I replied.

“Still….” he said and lingered by the patient’s room.  I started back to the nursing station with the resident trailing behind me. The nurse found the daughter’s number and the resident dutifully dialed the phone. He explained to the daughter about the lump and asked her permission to get a mammogram.

A frown clouded his forehead as the daughter spoke.

“But,” he said, “it’s probably cancer.”   He sat down twisting the phone cord into knots.

“Yes, but you must realize what might happen if we don’t do anything,” he started again.

Finally the conversation ended. He turned to me crestfallen. “The daughter says she does not want the mammogram. She says her mother has suffered enough.  She doesn’t care if it is cancer. She doesn’t want any intervention.” His face clouded over. “We could easily remove that lump now and she wouldn’t suffer.  Why are we even doing these exams? What is the point? Are we just going to let her die?” He dropped the chart down as if it was the lid of her coffin.

“It’s not our decision.” I replied.

“It will spread to her lungs and bones and she will suffer. We could prevent all of this from happening. he argued, “In my culture we venerate our elderly. That’s why I did this elective. How do we know the daughter has the best interests of her mother at heart?”

“We don’t know what the outcome will be; sometimes breast cancer can be indolent in the elderly. I’m sure the daughter  knows her better than us and has her  best interest at heart.  I wondered for a moment whether this was really true.  “We can speak to the daughter again if things change.” I added.

The resident dismissed what I said with a wave of his hand then turned on his heel and walked down the hall.  

‘Where is he going now?“ I thought. Then it dawned on me that he had gone back to the Mrs. Bass’s room.  I sprinted down the hall. He was talking to her.

“It looks like you may have a cancer in your breast,” he was saying.

“No, No, I don’t,” she shook her head.

“It would be better for you if we did something about it now before it spreads.”  He paused. “What do you think Mrs. Bass?”  

She folded in on herself.

“Mary,” he asked softly.

She didn’t answer.

I stood in the doorway and listened. How much did she really understand? He crouched down beside her.

“Mary?” he repeated and searched her face.

“I don’t know. I don’t know.” She frantically looked around the room as if the answer was hidden behind the furniture. She got up out of her chair, walked to the window, and pulled off her gown.

 “I ‘m not dressed and I have to go home.  I have to ask my mother.   Mother always knows best.”  She started out of the room. The resident started to follow. I shook my head and held him back. The nurse dashed after her with the gown.

“Maybe you can talk to the daughter at the family conference next month,” I suggested.

“No,” he shook his head. “I will be in Northern BC.”

 “I will mention your concerns to the daughter,” I said. He looked skeptical.

“I will,” I said, and I did.

Two years later I met Kim Lee at a CME event. He told me that he was a partner in an inner city family practice and worked at the neighborhood Chinese nursing home. He told me what a comfort it was for the patients to be able to speak to someone in their own language.

He asked me if I still went to the nursing home and then about Mrs. Bass.  I said she had died that Christmas.

“I hope she didn’t suffer. I never felt we were doing the right thing by just leaving her cancer,” he said with a set jaw.

“Oh, no,” I said, “she died in a flu outbreak; she didn’t die of her cancer”.

Theme: Death and Dying | Décès et le mourir
Theme: Family | Famille
Theme: Patients | Patients
Theme: Teaching and Learning | Enseignement et apprentissage

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.

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