The note on my desk read, "Please call nursing home administrator, re: a special admission".
Occasionally I'll receive a phone call from the admissions director at the local nursing home the next town over, but never from her boss. Truth be told, I didn't even know who the administrator was prior to seeing the note.
My interest peaked, I called back between patients. With stress and tension in his voice the head of the nursing home presented the situation, "Doctor, I'm looking for someone who will admit a patient whose wife has worked here for the last twenty eight years. He's seventy and until last week hadn't seen a doctor in thirty five years."
"Okay, why does he need to be admitted to the nursing home?" I encouraged him to get to the point because I still had patients to see and it had clearly been a while since he had presented a patient to a physician.
"He went to the hospital last week and was found to be in a blast crisis. He was recommended to go to the university for treatment, but he didn't want any part of it or any treatment, so he left the hospital against medical advice.
"He doesn't have any insurance that I know of and I don't even think he signed up for Medicare, and no one's going to get paid here, but we're just trying to help out this member of the staff. The patient is at home right now and I'd like to bring him in later today. All I need is someone to admit him."
Pausing to look at a copy of my schedule on my desk I remembered the medical director of the nursing home was about an hour away and for some unclear reason didn't particular care for taking care of dying patients, "Can you have him there by 3:00? I can come down around then and write some orders. And send me all of the hospital records too if you could."
Confirming what I said seemingly in disbelief, "Let me see if I'm hearing you correctly. You will be the attending physician of record and write orders on him if we can have him here by 3pm?'
A pre-medical student who had been with me during the day walked with me into the patient's room at the nursing home. Cachetic and with ashen face the dying man lay with his wife at the bedside. I introduced us and we reviewed the recent history and I examined the patient. He was already barely responsive and his breathing had become irregular. A terminal syndrome had started and he probably wouldn't live another 24 hours. I expressed my sympathy to the wife and gave her some idea what to expect over the next several hours as her husband died while she sat there.
Visibly moved the pre-medical student and I debriefed the experience. We talked about palliative care and hospice and how doing it well can be just as rewarding and meaningful as delivering a baby at the other end of life's spectrum. She seemed to appreciate what I had to say, but I know it will take years before she really understands.
The next morning the patient's new chart not even completely put together sat on my desk when I walked in the door. "Patient died at 10:32 pm." I filled out the death certificate for the man I never really had a conversation and signed my name to it.
The next day an apple pie and a box of chocolates appeared in our office from the nursing home staff. While this wasn't the reward I had in mind during my talk with the student, it sure made me feel all the better for doing it.