Dumbest dog in the world

Chester the chocolate lab died this week. I first met Chester when I was shuttling my youngest back and forth to the rural farm where she took riding lessons. The lane from the "hard road" to the barn was fairly long, and Chester ran full tilt toward the car's front wheels. It was only after this scene repeated itself every trip that I realized this was no usual creature. He was dumb. He did not seem to comprehend that a 3000 lb metal monster could possibly hurt him. After all, this nice young girl always was inside it, ready to give the horses (and the dogs) treats! With apologies to the dog in the currently popular movie, I truly believe Chester to be the dumbest dog in the world, or at least in the top (bottom?) 2%. His owners agree.

Sometimes, as I would be sitting in the car, windows down, waiting for the lesson to end and my daughter to emerge, Chester would leap around and chase unseen things. I personally think he may have had doggie schizophrenia, and was following "voices", but the owners said he liked chasing insects. When he tired of this activity, he would almost always top off his romp with a leg raised and a bodily function performed on one of my tires.

The lessons were twice a week, and my wife and I would trade shuttle duties, so I didn't really spend all that much time with this critter. I was surprised, then, at how badly I felt when I learned that Chester had been (you guessed it) run over by a car and killed. He wasn't that old, certainly not very slow, and the driver clearly had no fault in the accident. This dog, however dumb, was always very happy and energetic, and was, in fact, the quintessential dog: slobbering, unashamedly loving all God's fellow creatures, living or inanimate. It pains me to believe that unconditional love that strong has left this world.

It also reminds me that, like so very many of us, Chester died the way he lived. I have had multiple experiences of patients who live in houses where I am certain there is no electricity or running water, and conditions for their end of life care are less than optimal, but they love their lives for what they are, not expecting anything different. Or those whose lives have been lived "in the fast lane", and they die there as well. Those who deny they will ever die, and struggling to the last breath, and those who surround themselves with chaos during their lives so why would we expect anything less in dying?

Another three creatures died in my yard today. A small bird had built a nest in a window box. We discovered this fact when the mother bird flew out as we were watering. The nest was quite small, and difficult to see, but we watched it and indeed, saw three eggs. A great wind blew the whole box over today, and the hatchlings did not survive the fall. This, too, struck me in places inside myself that I didn't expect it to. How unfair! How tragic! Poor helpless defenseless birds. Yet these, too, died as they lived...in a precarious situation the mother bird chose for them.

My favorite newscaster of all time died today. I don't know the details other than he was 92, and had been near death at least for the week since the whole Michael Jackson and Farrah Fawcett debacle. But if he, too, died as he lived, his last words could very well have been, "And that's the way it is, Friday, July 17, 2009"

Death Certificate Frustration

I had a call today from one of the hospice nurses today. Seems one of the patients in our hospice had died, and his physician was out of town. He practices in a large group, yet no one in his practice would sign the death certificate. The physician would not be back for 10 days, and the deceased had arranged for cremation. Now, of course, in Illinois at least, you cannot be cremated without that piece of paper certifying that you are, in fact, truly dead. (To quote the Munchkins, not merely dead, but really most sincerely dead.) I had seen the patient once on a home visit for hospice, so I agreed to sign this document and allow the family to proceed with the necessary rituals surrounding their grief. 

Now, I fully admit that I may be more sensitive to this issue than some, but it comes as a result of my own personal experience. When my mom died just over a year ago, she had been under the care of a family physician who knew her for a long time. Unfortunately, this doc had endured all the change and hassle he could, and retired from clinical practice to take a teaching job; this occurred at the same time as mom needed to go in to a nursing home. The nursing home doc was happy to take over her care, and when her terminal event (aspiration pneumonia) happened, she was admitted to the hospital under the care of a hospitalist. This particular hospitalist group worked on a one week on at a time model.  Mom was admitted to the hospital on a Saturday, and died the following Saturday. The hospitalist who cared for her during her terminal illness then left on a scheduled vacation for several weeks, and so was unavailable to sign the death certificate. Her previous physician had already left the community for his teaching job, and the nursing home doc was only in town once a month, traveling to other nursing homes the rest of the time. So here we were, grieving the loss of our loved one, and as we finalize arrangements, the funeral director informs us that no one has agreed to sign the death certificate. 

We felt that this was a significant blow to our fragile states when we needed it the least. Of course, we could have waited for the hospitalist to return, but we were hoping to deal with the paperwork, insurance, etc., while the whole family was gathered, which would not be possible if we waited. So I pulled rank on the previous physician's group practice and persuaded them to have one of the partners there sign. Using guilt as a motivator and complaints as a tool, I was able to get someone to get the document completed and we were able to get our mom's affairs in order. My brother still seethes about this today, viewing it as adding insult upon the injury of grief. I admit I cannot disagree with him.

So when I saw this from the other side, it makes me wonder: what are we docs afraid of? Will the deceased sue us? Do we think someone is counting the number of deaths we attend, and if too many, we will be investigated? Are there simply docs out there that are truly out of touch with the needs of the surviving family members? Or who are just unwilling to do anything if it "isn't their patient"? (the latter attitude does exist, but I find it amusing since the doctor-patient relationship is becoming less valued by patients and payers. Possibly more on that in a future post). I suspect a combination of these is behind the issue.

I had occasion to speak with the senior physician in that practice and asked him if they had a policy about signing death certificates for each other. He said that they did not, but that most of them would be willing to do so IF THEY COULD REVIEW THE DEATH RECORDS (not the same thing as their own chart). Now, with all the different types of medical records systems, and documentation differences, most attending physicians get at best a summary of the final events, and probably this isn't enough for these particular docs. He did mention a SINGLE CASE wherein one of the (now retired) partners signed a partner's patient's death certificate within 10 hours of the death, only to find that the cause of death was being disputed due to some possible malpractice issue (a broken off piece of a catheter of some sort). This was later construed by the plaintiff's attorney as an attempt to conceal the truth. This evidently put such a bad taste in the mouth of the group that they were all gun shy about death certificates still, 10 years later. In my discussions with colleagues, this is the only case I have heard of with an issue surrounding certifying that a patient is really deceased, and what they died of. I have, however, run in to other situations where cremation was requested and the attending physician was unavailable and the covering physicians refused to sign. How absolutely tragic for the families. I know. I've been there.

One of the things I truly love about hospice and palliative care is that we get to be patient centered. I only wish all physicians had the privilege of that mindset.