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.

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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. 

Lily of the Valley is a member of the Asparagaceae family (and not the Liliaceae family, as you might think), Its scientific name is Convalaria majalis, and it is found across the Northern Hemisphere. It is toxic, and it contains a range of cardiac glycosides. These are compounds which can cause congestive heart failure, and the plants produce them as a defense. 

[Photo Source]

"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.

Let’s put the association between weight and mortality into perspective, shall we?

Excessive drinking increases the risk of developing head and neck cancers by a factor of 5 and increases the risk of liver disease by a factor of almost 10. [source

Smokers are 25 times more likely to develop lung cancer (the leading cause of death in the US) than non-smokers. [source

Having a gun in the home doubles the risk of violent death for everyone in the home and increases the risk of suicide for men by a factor of 10. [source].

Children who live in low-income families suffer 3 times the risk of all-causes mortality compared to children who are not raised in poverty, and experience 5 times the risk of death by homicide. [source]

Seniors who experience food insecurity due to poverty have double the risk of congestive heart failure, heart attack, asthma, and mental illness. [source

And what about fat???

Some studies report that being fat increases the risk of all-cause mortality by a factor of about 1.5. [source]

Yet even this weak association disappears or is even reversed (yup, fat people often live longer than thin people) when fruit and vegetable consumption, physical activity, and socioeconomic status are duly accounted for [source] [source] [source]

Weight is not the most important predictor of health and mortality. Not by a long shot.

- Mod D

“Hi everyone, this is my 3 ½ month old german shepherd puppy Nymeria. She is my lovable and playful baby girl and that’s why we need your help! Nymeria was born with a heart murmur and we recently found out it is caused by something called Patent Ductus Arteriosus (PDA). This causes abnormal blood flow in her heart which can lead to congestive heart failure and premature death. PDA is a genetic heart defect that affects 7 out of every 1000 puppies, and Nymeria happened to be one of those seven.  PDA can be fixed through surgery and Nymeria would be able to live a long life, but the costs are just too much for me as a college student. I hope all of you can find the time to at least share her story with others so she may have a chance to live a full life. If you would like to know more about PDA you can read about it here, akcchf.org.”

http://www.gofundme.com/helpnymeria