That Good Night
Life and Medicine in the Eleventh Hour
Sunita Puri 2019 / Beaverton Library 610.92 PUR
- med student studies palliative medicine
- p04 4th year UCSF med school, then three years of internal medicine
- p05 much time for tests and records, little time with patients
- p07 patient Donna: would a shorter life be better without dialysis
p08 Dr. McCormick; "two medicines help prevent gasping, toxins make you sleep, death after loss of consciousness, a merciful way to die."
- p09 patient dies after praying with chaplain
- p10 weeks before end of med school, Puri experienced caring for a dying patient
- p11 living well in the time remaining
- p15 Mother from Mumbai, grandparents West Punjab Hindu refugees, sectarian violence killed 1M - 2M people
- p16 grandfather taxidriver, 5 children in 2 room flat, 7yo daughter/mother decided to be doctor
- p17 begging and scholarships Mumbai medical school
- p20 author: I followed my mother into medicine because that's where she was
p22 Mr. Tan, patient writes: You are here in morning, afternoon, night. When do you go home?
- p29 family meeting with wife and daughter (UC Davis)
- p34 Puri attempts to communicate seriousness, Mr. Tan climbs (impossibly!) out of bed, says he WILL see is daughter graduate in 2 years
p40 I will suffer if you give up on me. As long as I am with them I will be OK
- p42 Two years later with Mr. Tan, watching daughter graduate
p43 I told you I would get out of here!
- p45 Second year, choose specialty training?
- p47 palliative medicine changed focus to quality of life rather than last months of life
- p49 parents (Anesthesiologist mom) dismissive of palliative care
- p50 pulmonary artery catheter, mother says "Now you know how long each one of those procedures takes. That's why I left home so early for so many years"
- p51 celebrated successful ICU treatments, troubled by patients in ICU for weeks or months
- p53 Puri redo: would have asked wife about husband's definition of suffering in ICU
- p59 Human suffering wasn't a topic we discussed in medical school.
p59 The Nature of Suffering and the Goals of Medicine book 1982 Eric Cassell
- p61 1970s, Karen Ann Quinlan, parents ask for natural death, doctors refused, New Jersey Supreme Court permits
- p61 Puri tells wife and son that patient only getting sicker, "we may be causing more harm and suffering"
- p63 life support removed, patient peaceful, dies 15 minutes later, wife thankfuk
- p65 Puri father says "if you pay attention and help ease the suffering of others, that is God's work"
- p67 spring 2012 Puri accepted into Stanford palliative care fellowship program starting July 2013
- p75 Puri chooses comfort care for dying patient, attending agrees "that's the difference between an intern and a resident"
- p90 stumble with daughter of first patient
- p92 some patients reject palliative care ("to save money"), others comforted
- p93 quality of life and treatment goals
- p96 Ideally, palliative care ... helps patients think through complex personal questions
- p111 Intubated patient Alice, combative husband Chris. Alice writes "no more tube"
- p112 sometimes supporting colleagues as much as supporting patients
- p114 extubations unpracticed, can be difficult
p139 Empathy isn't just listening, it's asking the questions that need to be listened to. - Leslie Jamison
- p139 First understand surrogate decision maker perspective in order to communicate
- p141 Don't offer procedure with no payoff
- p146 "But it is also a miracle that he is still here with us after everything he has gone through. And I'm not sure that would have happened without your love"
- p156 BCG (Bacillus Calmett-Guérin ) vaccine for tuberculosis
p179-205 SoCal hospital, many patient home visits
- p206 6 months allowed, US median hospice time 18 days
- p211 dementia patient pulls feeding tube out of abdomen, should have always been watched
- p214 thieves attack and steal pain pills from patients, come in the back without white coat
- p217 Chaplain Matthew - "...then it is all right to let go and let God"
p220 My friends who are doctors ask me how I deal with doctors whose patients are dying. Pick your battles
- p224 Puri freshman high school, anorexia
p250 Takes job at USC
p260 Talks with mother about her goals of care: OK if reversable, a few days of intubation, comfort but no heroics
p264 Lieutenant Dan from Forrest Gump
- p272 Adrian Gonzales, 4th year medical student
- p290 Grand Rounds presentation on palliative medicine, mother attends
- p292 slides replaced by discussion