Sunday, April 11, 2010

Protect the elderly from rationing of care

My dad was in great health until he was diagnosed with Colon Cancer in Spring 2007. At the time, he was 73 years old.

According to the partial autopsy report that I received from Duke University Medical, dad had two serious infections. One infection (pulmonary disease) was ignored by Duke Oncology and the other infection (bone infection) was ignored by Duke Orthopedics.

Course of pulmonary infection and where I (as care-giver) should have been more assertive:

In November 2007, dad was suffering from terrible infected sores all over his body. I tried to clean and bandage the wounds but my home care was not effective. The sores began smelling foul.

I took my dad to his Duke Clinic oncologist (Dr. Michael Morse) and the NP (Cindy Simonsen). Dr. Morse ordered that dad be transported directed from the Clinic to Duke University Hospital (North, in Durham) for "three days of IV antibiotics."

I sat with dad for several hours in the atrium lobby of Duke University Hospital (DUH) as dad shivered in a thin hospital gown. DUH did not even provide dad with a blanket. After I made a call to the NP Cindy Simonsen and asked whether we could just take him to a different hospital, there suddenly was a hospital room for my dad.

After I made certain that dad was admitted and being (apparently) cared for, I returned to my parents' home where mom was holding down the fort.

I returned to DUH and dad's room the next morning on my to a business trip to Charlotte, NC. And my impression of his care was frightening.

At DUH, the Duke Clinic physicians have absolutely no control over what happens to their patients. In this case, Dr. Morse ordered that dad have 3 days IV antibiotics. The hospitalist during hat admission was Dr. Hope Uronis. And, as with all other Duke hospitalists, there is no procedure for the Duke hospitalist to confer, communicate , cooperation or even follow the orders regarding the patient.

Dr. Hope Uronis told me that she did not think dad had an infection. Dr. Hope Uronis apparently disagreed with her colleague, Duke oncologist Dr. Michael Morse. Instead of speaking with Dr. Morse, Dr. Uronis simply ignored dad's clinical oncologist. Dr. Uronis is an oncologist herself. I wonder whether Dr. Uronis would be distressed if she wanted a patient of hers admitted to DUH and the hospitalist ignored her instructions.

I returned from Charlotte to pick dad up. He had the same bandages that I had placed on him. He was cold, in pain and confused. He was obviously very sick.

Dad received absolutely no antibiotics while an inpatient. In fact, if I had not been in Charlotte, Dr. Uronis would have discharged dad sooner than the 3 days.

No one could explain to me (1) would care or (2) pain management.

Dad came home on a Thursday. I had him back to the Duke oncology clinic and Dr. Michael Morse on the next day (a Friday). At that appointment, dad received some pain medication and I was instructed on wound management.

I brought dad home with me on Friday. It was a tough weekend for dad. On Monday, I returned dad to the Duke oncology clinic in Durham because he was having trouble breathing. Dr. Morse wanted dad to go to hospital through ED. But, since DUH (North, in Durham) did not comply with Dr. Morse's instructions 4 days earlier, Dr. Morse suggested I drive dad to Duke Hospital in Raleigh.

I asked whether Duke in Raleigh had access to Duke in Durhams records for dad. Oh yes, I was assured. Everything is computerized.

Dad was diagnosed with pneumonia. He remained in the Duke Hospital (Raleigh) a few days and then was released. No one ever followed up with dad's pneumonia. No medications for infection. When we left Duke Hospital (Raleigh), it was as though dad never had been hospitalized for pneumonia.

Dad was being treated at Duke oncology and no one ever mentioned pneumonia again.

Dad was cleared for orthopedic surgery by Duke orthopedic surgeon Dr. Mark Easley on February 14, 2008. At that surgery (a full three months after dad was discharged from DUH for the three day stay with Dr. Hope Uronis), the orthopedic team noticed a suture in dad's back.

Not only did Dr. Uronis ignore Dr. Morse's instructions for three days of IV antibiotics, Dr. Uronis also did not care enough to include an order on the discharge
instructions that dad return to clinic to have a suture removed.

In retrospect, I should have:

1. demanded that Dr. Uronis comply with Dr. Morse's instructions. I could and should have paged Dr. Morse or NP Cindy Simonsen and demanded communication with Dr. Hope Uronis.

2. refused to leave the DUH with my dad until someone instructed me on wound management.

3. demanded to know the cause of the pneumonia and the course of treatment. Thereafter, I could have followed the care to make certain that it was consistent with the articulated course of treatment.

Dad's autopsy revealed "end stage pulmonary disease." I never knew of early or mid stage disease. If I had demanded to know what the plan was for the pneumonia in 2007, perhaps dad would not have suffered so horribly as he struggled to breathe in his last hours of life. DUH knew that dad was prone to pulmonary disease. Pneumonia is the 4th leading cause of death among elderly.

My mom thinks perhaps DUH just wanted "to get rid of my dad." Maybe so, I was (and will continue to be) a patient advocate. Shame on DUH.

In my next post I will explain what I could have done to prevent dad from suffering from bone infection. That post will discuss the disappointment I encountered dealing with Duke University Orthopedics Fellows and Residents. On the whole, the Duke Orthopedic Fellows and Residents treated patients poorly and charted terribly. Sloppy charting is a sign of a sloppy doctor.

My tease for the next post was my encounter with Duke Orthopedic Resident Dr. Bret Peterson. Horrifying. He treated my dad terribly and disrespectfully while in the hospital. And, in classic Duke Orthopedic Fellowship and Resident Program arrogance, Dr. Bret Peterson told me that he did not care what his supervising orthopedic surgeon Dr. Mark Easley ordered. Dr. Bret Peterson explained to me that his job at DUH was to save Duke Hospital money.

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