The Surprise Question: Would Your Doctor Be Shocked If You Died?

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With studies showing an answer to the question is a significant prognostic indicator, it's a simple way of screening for palliative care eligibility.

Image: Odina/Shutterstock

My favorite example of someone being referred to palliative care, including hospice, and living longer is not Paul Gilliam or Mickey Zimble or Art Buchwald; it is my cousin, Edith Glikin.

Norman Glikin, Edith's late husband, was my mother's cousin. Edith and Norman were my parents' best friends. Growing up, they and their children, Sandy and Susie, were my favorite relatives. Our families spent a lot of time together. As a young boy, during a summer week I spent at their home playing with Sandy, Edith taught me to ride a bicycle, for which I am eternally grateful.

In late January 2004, at the age of 83, Edith underwent heart surgery. Things went well during surgery, but she had a very difficult recovery, marked by prolonged heart failure, breathing difficulties, dangerous cardiac arrhythmias, and profound depression. She was in the hospital for weeks, much of the time in pain and generally miserable. During the first weeks, she had to have a thoracentesis performed on three occasions to remove fluid around her lungs. In the larger scheme of medical procedures, it is not a big deal. But it was to Edith. In an X-ray suite, sitting on a cold table, her robe was removed and the sides of her chest were swabbed with iodine solution (also cold) as a disinfectant. A small shot of local anesthetic was injected in a dime-size area at a site on her mid-back, underneath which lay a pool of fluid. The radiologist passed a long, wide needle (roughly twice the diameter of a spaghetti noodle) between her ribs until fluid was returned. Then a guide wire was passed through the needle, the needle was withdrawn, and a firm, tapered plastic catheter about the gauge of macaroni was threaded over the guide wire and into the pleural effusion that had collected between the linings of the chest wall and lungs. The guide wire was then withdrawn and the outer end of the catheter was connected to a stopcock. Being very careful to maintain negative pressure on the catheter at all times, the physician who performed the procedure withdrew fluid into a large syringe. When he had drained all he could, the catheter and syringe were removed and a watertight dressing was applied to her skin. Then he repeated the procedure on the other side.

Edith lost all her appetite while in the hospital and, therefore, wasn't getting the calories or protein she needed to get stronger. She was unable -- or refused -- to participate in physical therapy. Edith thought she was dying and repeatedly asked her children -- Sandy and Susan -- and their spouses to let her go home. Several of her immediate family members, including Sandy, who is a pediatrician, his wife, Jenny, and sister, Susan, who are both nurses, worried that she might be dying. Edith's cardiologist disagreed. He explained that she merely had a shocked heart syndrome. It was unfortunate, he said, but it happens sometimes. While bothersome, he was sure she would eventually get better. With this assurance, the family acquiesced and prevailed upon Edith to go to a rehabilitation center. The first one was awful and was too far from her daughter, Susan, so after a few weeks she was transferred to another.

Things went from bad to worse and Edith, clearly failing to thrive, was readmitted to the hospital. Now there was concern that she needed a PEG tube to supplement her nutrition. Antidepressants that had been prescribed during her first hospitalization were changed. Edith continued to decline.

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Presented by

Ira Byock

Ira Byock is director of palliative care at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., and author of The Best Care Possible: A Physician’s Quest to Transform Care Through the End of Life.

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