I was on a run of late evening shifts recently in the Emergency Department, working through till 0200hrs, when I met Hazel and her daughters. Hazel had been feeling increasingly breathless over the preceding 2 or 3 days, but had hung on at home until she could get in touch with her GP on the Monday when she had asked her Doctor to visit her at home.
Her GP had dutifully visited her around lunchtime and noted her to have an irregular pulse, some noises in her chest, and some swelling in her ankles, and had arranged for an ambulance to bring her into hospital.
Monday is busy for all sectors of our society, and the health system is no different. GPs have many requests on their time, the ambulance service are often inundated with requests for emergency, routine and inter-hospital transfers, and hospitals have the highest number of planned and emergency cases to deal with. By the time Hazel's ambulance is able to transport her to hospital, it is late in the evening, and the service she was referred to is no longer accessible. She is deferred to the Emergency Department for her assessment.
This is not always the best basis for starting a professional consultation with a patient and her family, but this is the nature of our work. No-one plans to be in the ED, and generally people are having a bad day when they are with us.
It is now 2230hrs when I meet Hazel. She is 87 years old, sharp as a tack, but slightly toiling for breath. She describes her symptoms creeping up on her over the previous few days, with no sudden moment of onset, and that her predominant annoyance is her breathlessness. She has had no chest pain, no palpitations, no fever, no difficulty in eating or drinking, but has noticed some increase in swelling in her ankles and legs. Hazel has previously been diagnosed with high blood pressure and her heart no longer functions quite as well as before, and she is on tablets to treat these conditions already (which she helpfully has brought with her).
She lives alone and has, as she describes, "everything I could possibly need" in the house in terms of walking and living aids. She was not expecting to be in hospital this night, but is not one to complain or be contrary. Her 3 daughters, who are in their 50's and 60's, are sitting patiently in the cubicle with us, and all live nearby their Mum.
We have already got a heart tracing and some blood tests sent away, and whilst waiting for these to return, I examine Hazel. I agree with her GP's assessment: she has an irregular heartbeat, and has accumulated fluid in her chest and legs.
This opinion is strengthened by her heart tracing, which shows Atrial Fibrillation, and a chest XRay we order, that shows some fluid in her lungs. Her blood tests also show that whilst her kidneys, blood systems, and liver all seem to be in good (enough) order, a blood test that reveals damage to the heart muscle is slightly elevated. This blood test, called a highly-sensitive troponin (HS Tn-I) is released in many conditions, but is used to diagnose heart attacks. Whatever causes it to become elevated, we know that it suggests that patients are at risk of having a worse outcome, such as a stroke, heart attack, or even dying.
By now it is close to midnight, the ED is still humming with busyness, and I go in to explain our findings to Hazel. The "normal routine" for an 87 yr old lady with new atrial fibrillation, worsening heart failure and an elevation of troponin would be to offer admission to hospital to treat and review the response. This is even more likely at midnight, when it is incredibly difficult to co-ordinate transport, community services and discuss with the GP any management options.
On this occasion, though, I got the sense that this family would pull together if there were alternatives that might suit their Mum better. I asked Hazel "What would you like to do?"
"I'm going home, son."
No doubt there then. Her eldest daughter had a knowing smile, her middle daughter looked mildly concerned, and her youngest had her shaking head in her hands.
I went over the likely course of action if Hazel was admitted, but also what we could do and what we might expect if she went home. I explained that the chances of Hazel getting worse were real, but that we could start some tablets that could help the heart rhythm and the fluid in her chest, but that she would need to return if anything got worse, and certainly she should be checking in with her GP later in the week. I also was pretty frank about the chances of getting seriously ill.
"I'm 87, son. What are you going to do for me in hospital anyway?"
And there, in that nutshell, is the conundrum that faces us all too often in medicine. We follow guidelines and protocols without really questioning what our patients really want, and we lack the courage to share decisions and risks with them.
After another 10 minutes or so of discussion with her and her daughters, Hazel and I convinced her middle daughter to go and collect her car, return to the ED, and take Hazel back to her house. At 2am, she was discharged from the ED with a big smile on her face, some concern still in her family, but having determined her own course of treatment.