Patient receiving bad care - wwyd?

[Medstudent9]

So I am filling out an e-consult on a patient that I have never met who someone in my dept will see for a future procedure. I’m an attending anesthesiologist.

But I am a little horrified by what I see. He’s morbidly obese, OSA noncompliant with CPAP, severe COPD with FEV1 in the 40s, CAD with DES.

He’s also getting 100 mg of oxycodone a day for OA related pain, Ambien, benzos for anxiety. These drugs are going to kill him.

But I am not his pcp, no ongoing relationship.

What would you do? Anything?

If it matters, he gets all his care at my same facility so I can see all his providers and all their notes.

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[Goro]

Does this count as "SDN is not for medical advice"?????

 

[Medstudent9]

Does this count as "SDN is not for medical advice"?????

It’s not medical advice for me.

The details aren’t really important. If you in your practice see a patient getting dangerous but not illegal care, would you do anything? Comment in your note? Email their pcp? Just fill out the form and ignore it?

 

[gutonc]

It’s not medical advice for me.

The details aren’t really important. If you in your practice see a patient getting dangerous but not illegal care, would you do anything? Comment in your note? Email their pcp? Just fill out the form and ignore it?

I will often comment on it in my note if I feel that it's inappropriate. If it's flat out dangerous, I'll call the doc who's responsible.

That said, pretty much everything you listed has a high probability of killing this guy so....

 

[VA Hopeful Dr]

Consider those essentially hospice meds, because that's what they are at this point

 

[evilbooyaa]

The co-morbidities you can't do much about.

The medications, honestly, you leave alone IMO because you don't have a relationship with the patient. You can choose not to be okay giving anesthesia to a person like that, but unless you have a good relationship with that other doctor I wouldn't suggest changing the management. An e-mail/message stating your concerns to the PCP or whoever about anesthesia in this patient is reasonable.

 

[Medstudent9]

The co-morbidities you can't do much about.

The medications, honestly, you leave alone IMO because you don't have a relationship with the patient. You can choose not to be okay giving anesthesia to a person like that, but unless you have a good relationship with that other doctor I wouldn't suggest changing the management. An e-mail/message stating your concerns to the PCP or whoever about anesthesia in this patient is reasonable.

I agree I am not the person to be changing his meds, and his comorbidities are what they are. But someone with his comorbities has no business being on chronic opiates esp boatloads of them mixed with other sedatives.

Reading his chart was like watching a video of a car crash in progress and it bugged me. That’s someone’s grandpa/dad/spouse whatever.

I ended up putting in my A&P that he should be referred to a pain specialist for a taper and forwarding it with a note to his pcp.

Probably nothing will come of it but it won’t be on my conscience.

I just thought it was an interesting and timely dilemma.

 

[Winged Scapula]

It depends on who’s providing the care. It’s not clear to me when you say “PCP“ if the patient is actually seeing a physician.

If they’re being managed by a mid-level provider with inadequate physician supervision, I would contact the physician and express my concerns. Even in academic hospitals, complex patients may be seen and (mis) managed by MLPs.

If it’s a physician, I would make gentle suggestions in my note if I felt there was a better solution. If I felt what was happening was dangerous then I would pick up the phone.

 

[camkiss]

Attending anesthesiologist and pain management doc here: 50-50 practice. Before I answer, I’ll tell you I saw the inverse of this today in clinic. PCP of patient told him to tell me he needed stronger Oxycodone for pain. My answer: tell your PCP to mind his own business. My guess is you’ll get the same answer.
That being said, document multiple risk factors for post-op hypoxia and death, make him aware of the risk, make him and ASA 4, and proceed with the case unless further testing is needed.

 

[Crayola227]

Don't do anything you're not comfortable with and advocate for your patient, speak up.

One attending told me that some patients' psychic or physical pain is so great they feel compelled to seek a state that is as close to complete and total self annihilation, as close to death without dying as possible. Seemed apt and poetic. I respect physicians not taking part in it as much as I try to empathize with the patients for feeling they need to go to that place.

If I was this guy, I'm not sure I wouldn't be in a similar way. Maybe more intentional overdose than accidental. The current plan could be harm reduction in the scheme of things. Maybe not.

Just my musings on bad breathers trying to gasp their way through the night.

 

[PlutoBoy]

It’s not medical advice for me.

The details aren’t really important. If you in your practice see a patient getting dangerous but not illegal care, would you do anything? Comment in your note? Email their pcp? Just fill out the form and ignore it?

I deal with this fairly often. I tell the patient that this is not correct and strongly advise them to allow me to taper it off. Their answer is usually no. At that point I ask them to follow up with the quack du jour that put them on this marvelous cocktail of drugs.

 

[VA Hopeful Dr]

Don't do anything you're not comfortable with and advocate for your patient, speak up.

One attending told me that some patients' psychic or physical pain is so great they feel compelled to seek a state that is as close to complete and total self annihilation, as close to death without dying as possible. Seemed apt and poetic. I respect physicians not taking part in it as much as I try to empathize with the patients for feeling they need to go to that place.

If I was this guy, I'm not sure I wouldn't be in a similar way. Maybe more intentional overdose than accidental. The current plan could be harm reduction in the scheme of things. Maybe not.

Just my musings on bad breathers trying to gasp their way through the night.

My thoughts as well. This dude is going to be dead by the end of the year, let him go out comfortable.

 

[WingedOx]

My thoughts as well. This dude is going to be dead by the end of the year, let him go out comfortable.

Of course you can come to my clinic and see no shortage of otherwise "healthy" patients in their 50s coming in from community providers on the same completely bonkers benzo/opioid combinations. It's so frustratingly common in the blue collar suburban clinics I cover.

 

[VA Hopeful Dr]

Of course you can come to my clinic and see no shortage of otherwise "healthy" patients in their 50s coming in from community providers on the same completely bonkers benzo/opioid combinations. It's so frustratingly common in the blue collar suburban clinics I cover.

Oh yeah those people totally exist, but based on the 2 sentence clinical story we've got here, this dude does not fall into that category.

 

[d2305]

He's missing soma which they are on too.

 

[cbrons]

So I am filling out an e-consult on a patient that I have never met who someone in my dept will see for a future procedure. I’m an attending anesthesiologist.

But I am a little horrified by what I see. He’s morbidly obese, OSA noncompliant with CPAP, severe COPD with FEV1 in the 40s, CAD with DES.

He’s also getting 100 mg of oxycodone a day for OA related pain, Ambien, benzos for anxiety. These drugs are going to kill him.

But I am not his pcp, no ongoing relationship.

What would you do? Anything?

If it matters, he gets all his care at my same facility so I can see all his providers and all their notes.

Lol at “provider”

AKA his VA nurse practitioner

 

[BGDino]

Note your concerns and email/call/write to the PCP. This guy probably needs a referral to addiction medicine (not necessarily for detox, more risk assessment and consideration of containment strategies) but that’s probably best suggested to the PCP in a way that’s not via the notes (in my experience patients and some doctors don’t respond well to the suggestion of addiction medicine involvement... I’m an addiction medicine physician and have spent a lot of time calming down angry and offended patients who don’t understand why they’ve been referred to me...)