“Can’t you just prescribe it for me?” my patient asked me as she sat across from me in the exam room. This patient, whom we will call Mary, had stage 4 colon cancer. She was very matter-of-fact and a practical woman. As her primary care physician, we discussed her wishes and what was important to her. She had quite a bit of abdominal pain, and was hoping I would continue to prescribe her the Dilaudid pills that seemed to work well. But there was a problem.
This patient had been admitted to hospice recently after I had referred her. The nurse was coming to her house, and things were going well. But Mary insisted on seeing me every month. I was her doctor. The hospice nurse tried to explain to Mary that hospice and the hospice medical director took care of things like her medications. It was an insurance issue. Despite this, Mary showed up every month to see me, and we reviewed her symptoms and goals. In the end, the hospice nurse started calling me for things regarding Mary. As Mary said, I was her doctor.
This was not the first time as a primary physician that I stepped into the hospice provider role. Just before Mary transitioned to hospice, another patient (and also the mother of a good friend) took a turn for the worse. She had stage 4 ovarian cancer. Suddenly, I was managing her medications and coordinating care until hospice could admit her, which would not be for a week. I called them once a day while away in Kansas visiting family for the holidays. She died before hospice could admit her.
These circumstances certainly stretched me as a primary care physician. I wasn’t trained in hospice and palliative care medicine, yet here I was, called upon to do it. These patients relied on me. I was their doctor. I knew them, and they trusted me. Their families trust me. They wanted me involved. As I reflected on these experiences, the gravity of it all hit me. It was then that I realized how humbling and rewarding palliative care is, and how crucial it is for primary care physicians to be trained in at least basic palliative care and hospice medicine. For me, working in a rural critical access hospital on the Salish Kootenai Reservation, your friendly palliative care consultant or hospice agency were not just down the street.
Primary care is the crux of medicine. And while we need more specialists in palliative care and hospice medicine, our primary care providers need to be trained and empowered to provide this as well, because, whether they want to or not, whether trained or not, they may be called upon to provide this care. I know I was.
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