Another marker of success at the office?

today an older couple was referred to me by a physician working at Lovelace (our local for-profit hospital system owned by a corporation out of Tennessee). I've never heard of this doc and have no idea how the word of mouth traveled. the patient is a 59yo male with complex medical problems who is uninsured, cannot qualify for disability, is a few years away from Medicare eligibility and is in a load of trouble. signs of heart failure, liver failure, cellulitis on his right lower leg with profound bilateral edema to the knees; still smoking cigarettes and drinking alcohol (5-6 per day). he was stable, communicative and able to commit to a course of therapy which includes daily clinic visits until his symptoms are under control, otherwise i would have had to send him directly to an ER...

in the language of my past, i would have called this a "system dump." this man needs thousands of dollars worth of studies just to figure out his current baseline and then alot of medical visits to optimize his chances of survival, something a for profit system with a committment to their shareholders isn't going to tolerate.

in the language of my present, this is a man who needs help on alot of levels. he has clearly abondoned his own future and yet his one wish, when you ask him, is to live a long healthy life. his wife tells me he has heard the same information i shared about diet, medications and quitting alcohol numerous times and cannot find the willpower to make the moves. i tried to put some fear into him, realistic fear because the guys in trouble. he has recent blood work showing decreases in all his electrolytes and significant anemia... ominous signs.

the fundamental deal from my perspective is not the pathophysiology of heart failure but the failure of his survival instinct to kick in and motivate him to make radical changes in some basic aspects of his life. without that survival desire, without this man acting as his own most personal ally, what can anyone else do for him but hold his hand and comfort him in his final days?

so if i have a bit of success in calming the man's most acute problems, my next step is to understand if his apathy is from some kind of dementia, depression or hopelessness and then figure out some kind of remedy that gives him back his future. if he has already completely abandoned ship, ain't no way i'm going to try to paddle it for him. we each have to know our limits.

andru