congestive heart failure

A doctor discovers an important question patients should be asked

This patient isn’t usually mine, but today I’m covering for my partner in our family-practice office, so he has been slipped into my schedule.

Reading his chart, I have an ominous feeling that this visit won’t be simple.

A tall, lanky man with an air of quiet dignity, he is 88. His legs are swollen, and merely talking makes him short of breath.

He suffers from both congestive heart failure and renal failure. It’s a medical Catch-22: When one condition is treated and gets better, the other condition gets worse. His past year has been an endless cycle of medication adjustments carried out by dueling specialists and punctuated by emergency-room visits and hospitalizations.

Hemodialysis would break the medical stalemate, but my patient flatly refuses it. Given his frail health, and the discomfort and inconvenience involved, I can’t blame him.

Now his cardiologist has referred him back to us, his primary-care providers. Why send him here and not to the ER? I wonder fleetingly.

With us is his daughter, who has driven from Philadelphia, an hour away. She seems dutiful but wary, awaiting the clinical wisdom of yet another doctor.

After 30 years of practice, I know that I can’t possibly solve this man’s medical conundrum.

A cardiologist and a nephrologist haven’t been able to help him, I reflect,so how can I? I’m a family doctor, not a magician. I can send him back to the ER, and they’ll admit him to the hospital. But that will just continue the cycle… .

Still, my first instinct is to do something to improve the functioning of his heart and kidneys. I start mulling over the possibilities, knowing all the while that it’s useless to try.

Then I remember a visiting palliative-care physician’s words about caring for the fragile elderly: “We forget to ask patients what they want from their care. What are their goals?”

I pause, then look this frail, dignified man in the eye.

“What are your goals for your care?” I ask. “How can I help you?”

The patient’s desire

My intuition tells me that he, like many patients in their 80s, harbors a fund of hard-won wisdom.

He won’t ask me to fix his kidneys or his heart, I think. He’ll say something noble and poignant: “I’d like to see my great-granddaughter get married next spring,” or “Help me to live long enough so that my wife and I can celebrate our 60th wedding anniversary.”

His daughter, looking tense, also faces her father and waits.

“I would like to be able to walk without falling,” he says. “Falling is horrible.”

This catches me off guard.

That’s all?

But it makes perfect sense. With challenging medical conditions commanding his caregivers’ attention, something as simple as walking is easily overlooked.

A wonderful geriatric nurse practitioner’s words come to mind: “Our goal for younger people is to help them live long and healthy lives; our goal for older patients should be to maximize their function.”

Suddenly I feel that I may be able to help, after all.

“We can order physical therapy — and there’s no need to admit you to the hospital for that,” I suggest, unsure of how this will go over.

He smiles. His daughter sighs with relief.

“He really wants to stay at home,” she says matter-of-factly.

As new as our doctor-patient relationship is, I feel emboldened to tackle the big, unspoken question looming over us.

“I know that you’ve decided against dialysis, and I can understand your decision,” I say. “And with your heart failure getting worse, your health is unlikely to improve.”

He nods.

“We have services designed to help keep you comfortable for whatever time you have left,” I venture. “And you could stay at home.”

Again, his daughter looks relieved. And he seems … well … surprisingly fine with the plan.

I call our hospice service, arranging for a nurse to visit him later today to set up physical therapy and to begin plans to help him to stay comfortable — at home.

Back home

Although I never see him again, over the next few months I sign the order forms faxed by his hospice nurses. I speak once with his granddaughter. It’s somewhat hard on his wife to have him die at home, she says, but he’s adamant that he wants to stay there.

A faxed request for sublingual morphine (used in the terminal stages of dying) prompts me to call to check up on him.

The nurse confirms that he is near death.

I feel a twinge of misgiving: Is his family happy with the process that I set in place? Does our one brief encounter qualify me to be his primary-care provider? Should I visit them all at home?

Two days later, and two months after we first met, I fill out his death certificate.

Looking back, I reflect: He didn’t go back to the hospital, he had no more falls, and he died at home, which is what he wanted. But I wonder if his wife felt the same.

Several months later, a new name appears on my patient schedule: It’s his wife.

“My family all thought I should see you,” she explains.

She, too, is in her late 80s and frail, but independent and mentally sharp. Yes, she is grieving the loss of her husband, and she’s lost some weight. No, she isn’t depressed. Her husband died peacefully at home, and it felt like the right thing for everyone.

“He liked you,” she says.

She’s suffering from fatigue and anemia. About a year ago, a hematologist diagnosed her with myelodysplasia (a bone marrow failure, often terminal). But six months back, she stopped going for medical care.

I ask why.

“They were just doing more and more tests,” she says. “And I wasn’t getting any better.”

Now I know what to do. I look her in the eye and ask:

“What are your goals for your care, and how can I help you?”

-Mitch Kaminski

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My Mom was diagnosed with CHF. Nothing makes sence. I don't know what to think or feel.

(CHF is congestive heart failure) I mean what am I supposed to feel? Should I be angry? Should I be hysterically crying? (I cry every time I see her or talk to her and she is in the hospital right now) Should I be questioning god’s plan? What do I do when she comes home? Do I go on as if nothing happened? As if she isn’t suffering this horrible condition and ultimately death. As if I don’t have to see her everyday suffering? Maybe I’m in denial. I don’t know. I don’t understand how something so horrible can happen to such a good person. To such a good mom, friend, wife, co-worker, daughter, etc.

Keep reading

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Heartmate II LVAD implantation surgery narrated by Arie Blitz, MD

Ventricular assist device, or VAD, is a mechanical circulatory device that is used to partially or completely replace the function of a failing heart. Some VADs are intended for short term use, typically for patients recovering from heart attacks or heart surgery, while others are intended for long term use (months to years and in some cases for life), typically for patients suffering from congestive heart failure.

Medicalese101: CHF, JVD
  1.  nagisahaazukii said: I’m a second year and this post taught me what jvd and chf are (i just didn’t know it in shorthand)

This one’s for you, nagisahaazukii.

CHF (congestive heart failure): condition in which the heart does not contract or relax efficiently (or both), due to a stiff, floppy, or irregular ventricular wall. When the cardiovascular system is unable to compensate for the heart’s impairment, a patient can have a CHF exacerbation, in which pressure builds up in the vasculature behind the heart (the lungs and the peripheral veins) and fluid leaks out of the vessels. Clinical signs of a CHF exacerbation include lower extremity pitting edema (from all that leaky fluid), crackly sounds in the lungs and shortness of breath, again from fluid being where it doesn’t belong, and JVD, or jugular venous distention.

JVD is a measurable distention in the external jugular vein when the patient is sitting at about 45 degrees. It reflects increased pressure in the right atrium of the heart. 

2

Condolences

As World War II raged on Franklin D. Roosevelt’s health rapidly declined as he suffered from coronary artery disease, congestive heart failure, high blood pressure, and angina. On April 12th, 1945 Roosevelt said, “I have a terrific pain in the back of my head” before suddenly slumping forward in his wheelchair. Roosevelt suffered a massive stroke resulting in a cerebral hemorrhage. 

The death of Roosevelt would be followed by a 30 day period of national mourning. Heads of state from all over the world took the time to express their condolences for the President’s death. One most unexpected expression of condolence came from Japan.  At the time the Battle of Okinawa was raging, one of the most savage battles of the Pacific Theater, American bombers were incinerating hundreds of Japanese, Allied military leaders were drawing up plans for the invasion of Japan, and Japanese military leaders were planning the mass execution of POW’s.  So it certainly came as a shock when Japanese Prime Minister Kantaro Suzuki spoke this message in an English language broadcast from radio Tokyo,

“I must admit that Roosevelt’s leadership has been very effective and has been responsible for  the Americans’ advantageous position today. For that reason I can easily understand the great loss his passing means to the American people and my profound sympathy goes to them.” 

wtol.com
Kids and heart problems, know the signs

Congestive Heart Failure, doctors say, is weakening of the heart muscle, causing the heart to pump blood and oxygen at abnormal levels. When it comes to illness in kids,

“It’s uncommon and it’s actually rarely discovered,” said Dr. Ameer Kabour, Chief of Cardiology at Mercy St. Vincent Medical Center in Toledo.

"imagine my heart; filled with love. Given to you without hesitation"

I wrote this for my mom for Mother’s Day. Never in a million years would I have guessed that the very next day my mom would be in the hospital, diagnosed with congestive heart failure. Right now her hearts only working 25% and the quote above wasn’t just some sweet shit I said to make her happy, I meant it. Still do.

npr.org
The Art Of The Sitcom Grandparent: Remembering Clarice Taylor

                        

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Clarice Taylor died Monday at the age of 93 from congestive heart failure.

Taylor played Anna Huxtable, Cliff’s mother, on The Cosby Show, beginning in 1984. She and Earle Hyman, who played her husband Russell, put together quite possibly the fullest portrayal of grandparents that the half-hour sitcom has ever produced.

things my drama teacher has said that paladins of voltron have definitely said;

  • keith: i don’t care what you like. wanna know a secret? i don’t even care what i like.
  • lance: i want all three of my names to be warfield. warfield warfield warfield.
    • shiro: lance, no.
  • pidge: adults just want you to sit down so you’ll get congestive heart failure and sell you lipitor.
    • shiro: pidge, no.
  • keith: smiling at me just makes me feel you’re hostile.
  • hunk: is anyone secretly wishing there was a bear outside that door? i like bears.
  • shiro: I never took notes. The only B i ever got was because i didn’t turn in a notebook of notes.
  • lance: i’m going to actually, physically fight you over this. I’ve watched a lot of WWE- I’m a master in chairs.
  • pidge: if my legs cost 40 million dollars like taylor swift, i would saw my legs off.
  • hunk: what if the New York Giants were actually giants? they would win so many games. the New York Actual Giants.
  • shiro: catching rides with upperclassmen is how you get buried in a field
    • pidge: … how do you know this?
    • shiro: im not buried in a field.
  • hunk: before i die I’m going to eat a bunch of popcorn kernels to make the cremation process really interesting
    • shiro: hunk, no.
  • keith: what? club going up on a tuesday? i don’t know what that means.
  • shiro: i had two friends. sam and matt. …i think matt is dead.
    • shiro: hey i should check if matt is dead.
  • hunk: do you know that polar bears and grizzly bears are starting to mate and they’re creating a new species that’s a larger bear called grolar bears and it is going to kill us all.
    • pidge: they’re called pizzlys not grolar bears.
    • hunk: that’s a dumb name I’m choosing grolar bear.
  • shiro: i was a teenage boy at one point, i know what they’re up to. they do bad things.
  • lance: i am the best holder of grudges. i still have grudges when i was 3
  • keith: peach emoji is a butt ??
  • hunk: if unicorn horns were a snack we would call them crunchy horns
  • shiro: GUYS YOU HAVE TO GET YOUR SHIT TOGETHER NOW.
  • pidge: IM A GENIUS. Wasted. On you fools.
  • shiro: i want a hippopotamus for christmas is a terrible idea. hippos are so violent. that song suggests a christmas morning murder.