Last Round

November 10, 2010

As a resident teacher, I try to make bedside rounds relevant by identifying the needs of my learners and demonstrating key points at the bedside. The topic this day was management of a patient at end of life. Our patient was signed out to the team as a 70-year-old former executive with metastatic colon cancer who had been admitted overnight. Five different regimens of our best new drugs had made no impact, and he had arrived to emergency care with progressive colonic obstruction.

As a resident teacher, I try to make bedside rounds relevant by identifying the needs of my learners and demonstrating key points at the bedside. The topic this day was management of a patient at end of life. Our patient was signed out to the team as a 70-year-old former executive with metastatic colon cancer who had been admitted overnight. Five different regimens of our best new drugs had made no impact, and he had arrived to emergency care with progressive colonic obstruction.

When I introduced my subject to my listeners, I was surprised that only one had ever been with a dying patient. I made some brief comments about seeking to determine a patient's understanding of his condition as well as ascertaining his goals, and I gave a basic introduction to symptom-based versus disease-based care before we all entered.

I was somewhat surprised to find my patient in good spirits. He had slept well and was still sharp and coherent despite needing narcotics overnight. He wanted to hear all his potential options, including the risks and benefits of each. We discussed the merits of a colostomy, a palliative colonic stent, experimental chemotherapy, and using pain medications only. He collected the information and repeated it back to me to make sure he had it right. As we exited, I told the group that getting to know the concerns and expectations of key family members was also very important, and that I would need to come back later to explore this in order to best plan his care.

Later that day, I met his wife, two children, and a few friends. My patient had clearly understood what we had discussed that morning, and I was happy to see that he had already explained it to the family. I probed a little further and found an avid golfer, a lifetime baseball season ticket holder, and an active member of his local church.

The other dynamic that interested me was just how important serving his family was to him. After his family had stepped out, he went over with me the factors he was considering in his decision, all of which revolved around helping the family deal with the grief of his passing. His wife had a weak heart; he told me that she couldn't handle bad news in large amounts. His daughter knew this was coming but was having a rough time of it now.

And what did he have left to do, I asked? To ease his family's suffering, to help them through this transition, he told me. Our conversation turned to venue. Where did he want to spend his remaining time? He had no strong feelings either way. What did he have left to accomplish? "Nothing," he answered, with eyes projecting the serenity of a completed life.

"Actually, I just thought of one thing I'd love to have." He looked past me, over my shoulder.

"Have you ever had a beer from those new aluminum cans they only sell at the ballpark?"

We talked for a few minutes about it, about the memories that brought to him. We both concluded that it would be a great reason to get home, both knowing that he had almost no chance of becoming strong enough to make it to his ballpark seat again.

My resident and I left the room, and we embarked on a discussion about factors associated with serenity at end of life.

My thoughts then quickly turned to an internal debate of ethical principles.

Beer couldn't leave a stadium.

Doctors on shift shouldn't leave work.

Alcohol was forbidden on the hospital premises.

Teachers taught their students to respect the rules.

Against that stood:

A doctor is an advocate for his patient.

Two hours later, following a plea to a ballpark executive, a road trip to a stadium with my resident, and transport in an unusually packed white coat, my patient's eyes lit with delight.

One resident, one son, one attending all sat with one beaming patient enjoying one last beer in one final round. His eyes looked past me once again, into the baseball fields of his memory.

I have attempted to instruct in many venues, on disease and therapy, on life and death, on showing compassion and keeping balance, but never with so few words have I better conveyed the essence of being a doctor.

And to this day, that was the greatest beer I never tasted.