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"

• p85 Burlingame spacious tiled library

• 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