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The Patient's Story

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Mrs K is an 89-year-old woman with multiple medical problems and declining physical function. Dr T has cared for her since 1985. She has long-standing coronary artery disease with a history of myocardial infarction and had undergone 4-vessel coronary bypass graft surgery in 1991. Since 2001, she has been treated for atrial fibrillation and congestive heart failure (CHF) with warfarin, digoxin, furosemide, enalapril, potassium, and aspirin. Mrs K also has gastroesophageal reflux disease, hypothyroidism, and migraine headache, managed with famotidine, l-thyroxine replacement, and low-dose amitriptyline prophylaxis, respectively.

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Mrs K lives at home with her son. She is resolutely independent in cooking, bathing, and dressing, but her son helps her with her medical appointments and other instrumental activities of daily living (IADL) such as shopping, transportation, and finances.1 Mrs K came to Dr T's practice about every 3 months until February 2005, when she stated that she was too weak to make the trip any longer, and Dr T started making every-other-month, then monthly, home visits.

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In 4 months, Mrs K had 3 hospitalizations, 1 for CHF and 2 for excessive anticoagulation, delirium, and hyponatremia. Thereafter, she decided that she never wanted to go back to the hospital. Over time, despite a reasonably good appetite and steady food intake, she lost weight, declining from 124 to 110 lb (55-49 kg) in 6 months. She fell several times, and she had increasing difficulty managing her medications.

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Noticing Mrs K's declining status and progressive weight loss, Dr T broached the possibility of hospice care. She and her son were unsettled by the hospice worker's discussion of end-of-life care and hospice services, so Mrs K declined. Six months after her initial hospitalization for CHF, Mrs K had another CHF exacerbation that was treated at home. Dr T then had a long discussion with Mrs K and her son about her uncertain prognosis and the benefits of early hospice enrollment, which included in-home support services that would facilitate her remaining at home, receiving medication management to help prevent hospital readmission, and building a trusting relationship with hospice personnel. He reassured them that he would continue to be Mrs K's physician and would work with the hospice agency. Mrs K enrolled in a community home hospice program later that month.

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As of a visit a month later, Mrs K was stable and functioning reasonably independently, with "good" and "bad" days. A housekeeper and a hospice nurse came twice weekly. The hospice agency brought morphine, atropine, and lorazepam for use as needed, and Dr T explained to Mrs K that these were for symptom relief in case of an emergency.

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Perspectives

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A Perspectives editor interviewed Mrs K and Dr T the following month.

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MRS K: I was born in Minnesota in the Depression days and we learned to work young. ...

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