Monthly Archives: September 2015

Spiralized Butternut Squash in Sage Brown Butter


Spiralizers. Hugely trendy right now. I recently got on the bandwagon myself. Being vegetarian I am not a stranger to using vegetables as substitutes for other foods, including pasta. This handy little gadget makes it really easy to get beautiful, uniform sized cuts from all kinds of veggies. No more struggling with a knife and peeler!  This is my inaugural spiralized recipe.  It turned out pretty well, I think. It was fun to crank out the gorgeous noodles. The brown butter was the tricky part- I don’t think I let mine get quite brown enough, look below for some hints on this.

Serves 2. Takes 30 minutes.


One butternut squash

2 tablespoons butter

10 fresh sage leaves

Olive oil

Fresh grated Parmesan and fresh ground pepper


Set up you Spiralizer of choice. Preheat oven to 400 degrees.


Peel you squash and discard the big bulbous bottom part that has seeds. Place the long upper part into your Spiralizer and start cranking.



When your squoodles are done, place them on a baking sheet with parchment paper and toss lightly with olive oil. place into the oven to lightly roast for about 7-8 minutes.

While they are in the oven, get your brown butter going. Use a light color pot, not a dark skillet so you can see the color of it while it cooks (I did not do this, a mistake on my part). Medium heat. The butter will melt and then star to bubble and foam. It will turn tan then brown. Some sediment will form in the pan. When it starts to tan, place your sage leaves in the butter.


When it gets a nice golden brown color, it’s done. Take your squoodles from the oven and toss them in the sauce.  Top with fresh pepper and Parmesan cheese.


** Adapted from Boulder Locavore

Fresh Corn Salsa and Black Bean Tacos


Tacos! There are endless recipes and variations for tacos, which is what I love about them. These tacos are made bright with the corn salsa, the corn right off the the cob. I layered it with a traditional tomato salsa and fresh avocado as well for a balanced bite. As you can see by the pictures these were pretty overstuffed, and I would up eating a lot with a fork. They would be great without the tortillas in a bowl as well with rice or quinoa, like any taco fixings.

Serves 4. Takes 30 minutes plus garlic roasting time


2 15 ounce cans black beans

1 white onion- diced and split half/half

1 whole bulb garlic, roasted. To roast garlic, chop off the bottom quarter. Leave in the peel. Cover in olive oil and place in foil wrap. Put in oven at 400 degrees for an hour. Garlic will be soft and light golden brown and easily pop out of its peel.

1 separate clove garlic finely minced

2 stalks corn, all kernels cut off

6 radishes thinly sliced

2 handfuls cilantro, finely minced and divided in half

2 limes both juiced, one zested

1 lemon

1 jalapeño minced and seeded

2 Serrano peppers (or 3 more jalapeño peppers)

1/3 cup feta cheese

1 handful pickled carrots, diced. To pickle carrots: place 1/2 cup white vinegar and 1/2 cup Apple cider vinegar in pot with 1/2 cup water. Add a pinch salt, pinch of crushed red pepper, and several slices of fresh jalapeño to the pot. While coming to a boil, peel and chop up several carrots into inch size pieces. Place into pot, bring to boil then turn off heat. Let cool then jar.

1can fire roasted tomatoes (15 ounce)

1 bunch green onions (ok to leave out)

1 avocado, sliced

Sea salt



Smoked paprika


Crushed red pepper


Place a sauté pan on the stove at medium heat with a tablespoon olive oil. When hot, add half the white onion to the pan. Cook until softened, about 5 minutes. Add minced garlic to the pan and cook another 1-2 minutes. Add the black beans with their juice to the pan. Season with about a teaspoon each: crushed red pepper, cumin, smoked paprika, and chipotle. Turn down heat to low and let simmer for about 20 minutes to cook off the bean liquid, stir occasionally.

While the beans are cooking you can make the two salsas to go with the dish.


My favorite quick salsa comes from Thug Kitchen. It uses canned tomatoes, but you would never know, it tastes so fresh. The only part that takes any time is roasting the garlic, the rest comes together in a few minutes in the food processor.  Add your roasted garlic, can of roasted tomatoes, half the white onion, a handful of the cilantro, the Serrano peppers, the green onion (if using), juice of one lime, 1 teaspoon salt, 1 teaspoon cumin, 1 tablespoon lemon juice and pulse together. For both this and the salsa below, I add a splash of lemon juice as I really love the brightness of lemons compared to limes. Or according to my brother, I just like Sprite and its lemon-lime goodness.  You can use immediately and jar the rest.


To make the corn salsa, place your fresh corn kernels in a bowl with the juice and zest of one lime, one tablespoon of lemon juice, one handful of minced cilantro, the feta cheese, the sliced radishes, the pickled carrots and add a teaspoon of salt. Mix together and set aside. This part of the recipe I found on Cookie and Kate. I added the pickled carrots for that extra punch of the vinegar.

Time to assemble your tacos! Heating up your tortillas on a skillet will give them a little extra edge. Start with a scoop of the black beans then layer the two salsas on top. Finish it off with fresh avocado.  One of the reason I like this taco recipe and similar ones to it, is because there is very little cheese. Just a little feta, which gives that nice salty punch. Cutting back on the cheese is good for us cheese-aholics!


** As stated above the roasted tomato salsa recipe is adapted from Thug Kitchen. I have a terrible mouth, so I love their hilarious recipes.

** Cookie and Kate is another great blog featuring wonderful whole food recipes and great photos (with a dog!)

Sweet Corn & Black Bean Tacos

Brussel Sprout and Wheat Berry Salad


I’ve already pontificated on my love of beets this week, but brussel sprouts are as amazing. My favorite way to cook brussels is to roast them in olive oil and cider vinegar sprinkled with salt and then just eat a big bowl full by themselves. Recently I’ve been incorporating them into more dishes, and this super easy and delicious, nutritious salad is one of those, from Oh My Veggies. Wheat berries are a grain similar to farro and barley. They have a nice hearty taste to them and hold up well to a myriad of ingredients. You may not be able to find them at your regular grocer- so try a health food mart or specialty grocer or of course Amazon because they have everything in the world (I may have an online shopping addiction).

Serves 4. Takes 30 minutes plus 50 minutes to fully cook wheat berries


2 cups red or white wheat berries

3 cups veggie broth and 2 cups water

1 pound of Brussel sprouts trimmed and halved

1 big shallot- chopped into small pieces

1/3 cup walnut pieces

3 tablespoons olive oil

1 tablespoon apple cider vinegar

1 large lemon- juiced and zested

1 splash red wine vinegar

1 tablespoon agave nectar

A pinch of salt and pepper



Place veggie broth and water in a pot or skillet and bring to a boil with your wheat berries. Turn down heat to a simmer and cook for  about 50 minutes, stirring occasionally.


Prep your brussels and shallot. Spread on baking sheet with 2/3 of the olive oil, the apple cider vinegar, and salt.


Place into oven and roast for 20 minutes. Then add walnuts and roast another 5 minutes.

Whip up a quick dressing with a tablespoon of olive oil, the juice and zest of the lemon, the agave nectar the splash of red wine vinegar, and a pinch of salt and pepper.

Drain the wheat berries. Place wheat berries and brussels mixture into bowl. Toss lightly with the dressing and bon appetite!

** Adapted from Oh My Veggies- a wonderful food blog


Pain Crisis

What is it like living in pain everyday? I know something of pain myself from a bad injury followed by multiple surgeries. It is enveloping and all consuming to be constantly in pain. I am fortunate because my pain finally got better after several bad years- what if your pain never got better?

That is a horrible reality many people are living in right now. The chronic pain population in this country is astronomical. Our offices, urgent cares, ERs, and hospitals are being overrun with patients whose pain is out of control.  They want a solution to this pain, and end to it.  But we cannot offer that.  In so many cases we do not have a fix, we cannot make the pain go away. So we talk about managing the pain, and coping with it. But the problem is many are not coping- they are turning to pain management for higher and higher doses of opiates. When they can’t afford them they are buying pills off the street. When they realize how much pills cost they start buying heroin to replace them. They lose their jobs, they lose their houses, they lose their families, and many lose their lives.

Does this happen to every patient with chronic pain? No, but we are seeing it more and more.  The heroin epidemic is real and soaring.  People of all ages, races and backgrounds are affected, and they are dying. Of overdoses, yes- but also of infections and severe medical complications of drug use. Lining the halls of our hospitals, they return again and again until the last time, when it is too late.  How many young people in their twenties and teens will we see die of florid heart failure from endocarditis? The numbers keep climbing and what used to be rare is now common.

How do we reverse this trend? How do we make the expectation that we very likely cannot rid you of pain, but slowly try and manage and reduce it? And do it all without any opiates?  Well, it will take a seismic shift in culture. We are so wired to the mentality of “take a pill and make it better” or “we can operate and fix that” that patients expect this when they come to us. To have to tell patients that we don’t have any quick fix is frustrating not just for them but for us as providers.  Getting a patient to accept as treatment physical therapy, exercise, cognitive behavioral therapy, medication for depression, tens units, injections, spinal stimulators, etc. when they really want something that will help right now in that moment- that is next to impossible. But it possible, and if we don’t change our culture this opioid addiction plague is going to become increasingly more wide-spread.  Many pain clinic incorporate all those previously mentioned strategies, but most patients complain that they have to “get through” the counseling, therapy, and other treatments in order to get their pain pills. If those opiate pain pills were taken off the option list, since they have been proven again and again to have little to no efficacy in treating the vast majority of chronic pain problems, then all that effort could be shifted to optimizing the modalities that have been shown to have a positive effect.

The demand for chronic pain management clinics and physicians is so high that we need more clinics where there multidisciplinary treatments can be given to patients. It takes months to get into pain clinics here in Ohio, and in the meantime most patients are getting by going to urgent cares and the ER to get short term pain pill prescriptions when they really need to be getting a jump start on PT, behavioral therapy, starting nutrition and exercise plans. Asking a primary care doc to deal with chronic pain is also a very difficult task- a patient will come in for a 15 minute visit with 5 chronic medical conditions that need addressed urgently but want to focus the whole visit each time on his chronic recurrent back pain. How can you keep a patient with morbid obesity, diabetes, and heart disease alive and going if you only get to treat their chronic pain issues every visit? In many cases, treating and improving chronic medical conditions (diabetes, obesity, depression) will also help improve and treat chronic pain, but again this is taking the long view and doesn’t offer any quick fixes for patients.  Many primary care doctors will not prescribe any opiates at all, which is a good strategy, however these patients then come to the ER and many ultimately end up admitted due to “intractable pain.” On the inpatient side of treatment we are then in a daily struggle with patients who want IV pain medications, which are not the recommended treatment for chronic pain conditions, and who don’t want to be discharged from the hospital because their pain is no better than when they came in.

Since I started medical school I have seen the problems and issues with chronic pain and opioids worsen ever year. It is creating a system in which more patients at more ages are on more long term pain medications. The consequences have been devastating to see and are continuing to accumulate. Reform is ongoing with more and more regulations over who can prescribe what narcotics. These regulations will help, but we have to keep working everyday stop the cycle of long term opiate prescribing.  The more rigid we are, the more boundaries we set, and the harder we make it to access opiates the less prevalent they will be in our everyday society and medical practices.

Burnt Carrot and Avocado Salad


This salad is one of those dishes I make again and again. The recipe comes from Metropole restaurant in Cincinnati. It is easy to make, though it gets pretty smokey in the kitchen. If you happen to have a dog (or three) with a phobia of smoke alarms, take the battery out when you cook this one! A good cast iron skillet is essential to get that good char on the carrots.

Serves 2. Takes 30 minutes.


4 carrots

1 avocado- as firm as possible!

1 lemon

1 small handful of freshly minced cilantro and parsley

1 small handful feta cheese

2 teaspoons salt and pepper

2 splashes olive oil

1 small handful pickled red onions.  To pickle: take a red onion, slice thinly. In a pot on the stove add one cup cider vinegar, 1/2 cup water, 1 teaspoon salt, 1 pinch sugar, 1 pinch crushed red pepper. Bring to a boil with the onion in the pot, then turn off the heat and let cool. Place into a jar with the pickling liquid. Best used after 24 hours but can be used when cool.

1 handful toasted pepitas (may leave off if desired)


Place a pot of water on to boil (small). Peel four carrots and cut in half and then length-wise.  Use large carrots for the best result. Cook the carrots until just able to be pierced by a fork. Drain and pat dry.


Slice your avocado and place into a large bowl. Squeeze juice of one lemon into the bowl.


Add to the bowl a teaspoon of salt, pepper, the cilantro and parsley, the pickled onions, and feta cheese. Drizzle a splash of olive oil over the bowl and mix together.


Heat your cast iron skillet with a thin coating of olive oil. When hot (just at its smoke point) add your carrots, flat side down into the pan. Have your vent on high as it’s going to get smokey! Cook about 5 minutes then flip. You want to literally burn them and see beautiful char markings. When done, take off the pan onto a paper towel to remove excess oil.


To plate, mix carrots and avocado bowl fixings together.


** From Metropole restaurant

The Living Hospital

A hospital is like a living, breathing organism, and the bigger it is the more people and parts are required to keep it together. One thing the recent debacle on The View has shown, is that none of us do our job in a vacuum. So when Joy Behar made her idiotic and condescending comments about Miss Colorado’s “doctor’s stethoscope” she had no idea she would be insulting not just nurses, but the millions of others of professionals who use stethoscopes everyday to do their job. #nursesunite and #showmeyourstethoscope have really shown remarkably well how much passion and dedication people have for this field. There are so many people who make it possible for me to do my job everyday, I wanted to take a little space here to lay them out and thank them.

Environmental services. Not only do they keep our fancy hospital spotless but most of them are among the kindest people working in the hospital, and I am privileged to know them.

Security. Who I know will come and protect me from screaming patients who are trying to assault me and the nurses and PCTs.

Nutrition Services. Several of the gentleman who deliver food are so nice that many patients will ask after them when they are leaving the hospital.

Lab techs. Helping to get all the vital tests patients need.

Patient Care Techs. Unsung heroes. Helping patients eat, go to the bathroom, sit with elderly and combative patients, and many other jobs. They have very difficult jobs doing laborious work for not a lot of pay, they work very closely with patients and build up bonds with them, and they deserve a lot of credit.

Hospital Unit Coordinator: a special category for them because they are really helpful on each unit and really friendly HUCs make your day better.

Social Workers and Case Managers. Always put upon trying to get patients out of the hospital faster and faster. Having to deal with wretched insurance companies. Trying to help steer anxious and despondent families through the process of going to a nursing home- which is now routine and not the exception. We rely on them a great deal.

Therapists: speech, PT, OT; helping our patients regain their functions, sometimes after completely devastating stroke or illness.

Pharmacists: we deal with ever more complicated medications especially with more people living longer and having more diseases and renal and liver problems- our pharmacists are essential partners in working out of medication strategies for patients

Chaplain: this is an obvious need. We see much loss and sorrow in the hospital and we need all the support for families possible.

Porters/Transportation: getting our patients safely from place to place

Radiology techs: especially when we need important tests done really quickly on very sick patients- awesome.

Nurses: the backbone of the hospital. Providing the one on one 24 hour care to patients. As physicians we may only physically round in a patient’s room for 5-10 minutes. We rely on our nurses to be our eyes and ears. Is the blood pressure dropping? Did they spike a fever? Have they urinated all day? Crucial information that the nurse will notice and relay to us.  Is the patient breathing harder? What do their lungs sound like? The nurse will be the one at the bedside that moment to listen and tell me so we can make a plan together. Do we have a critically ill patient we know is going to die? In that case I will have come in, talked to the family, comforted them and the patient- but who is in the room when the patient’s heart stops beating? Not me, the nurse. She or he will call me and let me know, but they will be the ones with that patient and family in those final moments. Indispensable.

Advanced practitioners: working alongside physicians in many different capacities to treat patients. Including PAs and NPs, there is a very broad range of skill sets and duties.

And that leaves doctors. There are a lot of us in a lot of different specialties coming together to figure out solutions on really sick and complicated patients. Without all the other people above, though, we’d just be blowing a lot of hot air.

Roasted Beet and Grain Salad with Citrus Vinaigrette


I had never eaten a beet until maybe two years ago.  Same with brussel sprouts.  Oh, what I was missing all my life!  I now eat both whenever I can.  I have only recently taken to tackling the beet at home, but I needn’t have worried. Roasting beets is just like roasting anything else- it is easy as pie.  And the end result is so so so delicious!  You can use the roasted beets for any recipe you like, or just eat them right out of the oven when they are cooled down.  In this absolutely delightful salad, they shine alongside all the other ingredients.  This salad is just a marvel of bright acidity, and I love it.  I only slightly tweaked this one from the original recipe, which comes from The Grocery Cafe at Deer Valley Resort.

Serves 4.  Takes 1 hour fifteen minutes (including roasting time on the beets).


For the salad itself:

4 cups of arugala

2 large beets (any color and variety will do just fine)

1/2 cup of goat cheese

3/4 cup of barley or farro or wheat berries

For the candied pecans:

3/4 cup raw pecans

2 tablespoons maple syrup

2 tablespoons sugar

For the citrus vinaigrette:

2 lemons juiced and zested

2 oranges juiced and zested

1 clove garlic finely minced

1/4 cup agave nector

1 cup olive oil

1 tablespoon Dijon mustard


To roast the beets turn oven to 375 degrees.  Start a pot of water boiling now as well for your grains. Place each trimmed and washed beet in a packet of tin foil with olive oil and salt.  Place in the oven.  Leave about 45 minutes for smaller golden beets.  60 minutes for larger red beets.  Cook your grains according to directions of what you are using.  Barley takes quite a while to cook at least 30 minutes, so don’t forget to start it early. While the beets are roasting and your grain is cooking, you can continue with the other components, see below.


When you remove your beets they will be soft and succulent.


Let the beets cool.  Then peel them- wear gloves or you will get beet juice all over you!


Give them a uniform small dice and set aside in a bowl.  Take pictures of them to show off to your friends, they are beautiful!


You can get your nuts candied in the oven at the same time your beets are roasting in there.  Place them on a baking sheet, mix with the syrup and sugar and place into oven for about 20 minutes.


While everything else is on the timer, do your vinaigrette.  Place all components above into food processor and blend until smooth.  Place into bottle and set into fridge.


To plate: start with a bed of grains.  Top with arugula, which has been lightly coated with the dressing.  Next goes the beets, candied pecans, and goat cheese- crumble and evenly sprinkle over the salad.  Give the top an even drizzle of vinaigrette, and mwah!  So beautiful, lets look at it again.  And it tastes even better!


I put my extra beets, nuts, and barley into jars and tupperware so I can continue to eat them into the next week.  Since I am the only vegetarian in my house, I am the only one eating this recipe, and I will eat it multiple times in the next few days.  I look forward to it greatly, this has to be one of my top salads I’ve eaten.

** Adapted from a dish served at Grocery Cafe at Deer Valley and recipe found at Love and Olive Oil

Roasted Beet and Farro Salad with Citrus Vinaigrette

Spicy Mac and Cheese with Cauliflower, Cashew Cheese, and Spinach


This is a recipe my husband, Rob, and I have been tweaking for awhile. The original recipe was just a basic mac n cheese and we’ve been adding to it to make it healthier as time has gone on. It still has a good amount of regular ol cheese in it, but we have rounded it out with more nutritious ingredients. I haven’t been able to make the leap to the vegan only version of this recipe with no cheese, but this is a big improvement from the original heavy cream and cheese-only versions.

Serves 6-8. Takes about 2 hours.


1 package spiral shaped pasta- roughly 14-16 ounces. I like Barilla Protein Plus as it has an excellent protein content. This time we used trottole since it was what we had around.

1 head cauliflower chopped roughly

1 cup cashew cheese. To make this soak 2 cups cashews in water for at least 2 hours. Then put in food processor with juice of 1/2 lemon, 2 tablespoons nutritional yeast, splash of olive oil, and one pinch each salt and pepper. Blend until smooth. You can make this ahead and keep in the fridge until you use it.

4 cups grated cheese. We use a mix of chipotle Gouda and extra sharp white cheddar

2 1/2 cups skim milk

4 large handfuls fresh spinach roughly chopped

EVOO- total a cup for whole recipe

1/4 cup flour

2 cups panko breadcrumbs

1/4 cups Parmesan cheese, grated

2 tablespoons fresh parsley, minced

4 cloves garlic, minced

Spices: crushed red pepper, smoked paprika, cayenne pepper and salt and pepper


Place two large pots of water to boil on the stove. In one cook the pasta until it’s al dente. Take it off, rinse in cold water, and set aside. In the other pot cook the cauliflower until it is just softened.  While these are cooking, heat a sauté pan with a splash of olive oil. Add the minced garlic and cook for 1-2 minutes. Add your chopped spinach and cook down until wilted, about 3 minutes. Take off the heat and set aside.


When cauliflower can be easily pierced with a fork, remove from heat, drain, and place in food processor. Add a splash of skim milk, a splash of olive oil, a pinch of salt and pepper and blend until smooth. Now add the cashew cheese to the food processor and again blend until smooth.  Place this mixture in a bowl, stir in your wilted spinach, and place bowl in the fridge until later.


In a bowl, combine breadcrumbs, parsley, Parmesan cheese, and olive oil to coat the crumbs. When well coated place mixture into the sauté pan you used before on medium heat. Toast these while stirring every few minutes, for 10-15 minutes until a nice light brown.  Turn your oven on to 375 to preheat.


While those are toasting, start your bechamel sauce.  In a large sauce pot stir together 1/4 cup olive oil with 1/4 cup flour to make a roux. A whisk is the best tool to use here. Add your flour gradually while stirring constantly. Don’t leave it unattended.


Next, slowly add 2 cups of skim milk, stirring continuously throughout. You should end up with a smooth and thick creamy sauce. Now add your cauliflower, cashew, and spinach mixture from the fridge and stir until smoothly blended. Your cheese goes in next, again stirring constantly. Add the spices to the mix- a teaspoon each cayenne, smoked paprika, crushed red pepper. Finally, add up to 1/2 cup milk to thin the sauce to desired consistency.


Get your pasta and stir into the sauce, coating evenly. Then place in casserole dish and top with breadcrumbs.  Bake for roughly 20 minutes and you are ready to serve!


This holds up extremely well for leftovers. Just add a touch of milk when you reheat in the microwave.

Pasta with Spinach, Chickpeas, and Burrata


I bought some wonderful fresh Burrata cheese at the grocery store the other day (right at my regular Kroger store, not at a specialty market!).  I had a couple of recipes in mind when I bought it, but when I found it in my fridge I had gone through all my freshly purchased tomatoes.  It was a rainy and gray day outside, so I had no intention of running out to the store.  I have made a similar pasta with chickpeas and spinach before, so I thought incorporating it into this nice lemony recipe would work out well.  It is a quick dish and the lemon and creamy Burrata really pair well together with the other elements.

Serves 4. Takes 20-30 minutes.


One container of fresh Burrata cheese (A good ricotta cheese or fresh mozzarella could be substituted instead)

One bag of pasta- I used trofie pasta but any small twisted shaped pasta would do

4 cloves garlic, minced

1 tablespoon butter

1/4 cup olive oil

2-3 large handfuls spinach, roughly chopped

1/2 can chickpeas (15 ounce) drained and rinsed

One handful of toasted nuts- I used pine nuts but almonds would work as well

1 lemon: juice the lemon and set aside juice.  Zest the outside of the lemon and set aside zest.

1 pinch each: salt, pepper, crushed red pepper


Place a large pot of water to boil.  Cook your pasta until al dente and then drain and rinse in cold water and set aside until later.

On medium heat skillet, Melt butter and add the olive oil.  When heated, add garlic and cook for about one minute, until turning golden.  At this point, add your spinach and chickpeas to the pan. Mix and cook down for 2-3 minutes.


After your spinach has wilted down, add lemon zest, salt, pepper, crushed red pepper, and your toasted nuts.  Stir and let cook for another minute. Now get your pasta and add it into the pan.  Coat the pasta with sauce and let sit on low heat.  Add your lemon juice to the pan and mix all together, letting cook for a minute or two.


Ready to plate and eat!  Just throw a few dollops of that beautiful Burrata on top and stir it up as you go!

** This was adapted from a recipe on Epicurious:

A Good Death

Starting off my medical musings talking about death may not be the way to reel people in, but the concept of a death and dying is one that you cannot avoid when you are a physician.  For most of our patients it is something that they never think about until all of a sudden it is upon them or a loved one.  Even those with known terminal diagnoses are still be taken aback by that moment of finality when you tell them that no, there is really nothing left we can do- this is the end.

Helping patients and their families at the end of life is at once the most difficult and rewarding part of my job.  The moment when you look a person and their loved ones in the eye and tell them that they are going to die is one of the most intimate things you will ever do.  Many times the person who is actually dying will be too sick to understand and their family will be listening in their stead. Each person and family needs to be told in a different way, because each person will cope with this news differently.  Some people will want all the news broken at once, so they can grieve completely and plan.  Some will want it delivered in stages and small doses, to preserve hope for as long as possible.  Every sentence out of your mouth is a litmus test for how to continue proceeding and to build up the relationship you have started with the patient and their family.  If you say the wrong thing, and you lose them, that bond is hard to build back up.  In those moments, it is very important to find out what the patient would want done at the end of life.  What does a good death mean to them?  For the vast majority of people it is not dying while in the ICU on a ventilator, but that is where a lot of these conversations take place- once that has already happened.

One of the hardest things to do as a caregiver is to stop giving care.  We are trained to “fix” and “do.”  Many times it is easiest to continue to press onward indefinitely then to really step back and look at what then end result is.  If the cardiology doctors have the patient’s heart stabilized with anti-arrhythmic medication, the pulmonary doctors have their breathing stabilized with a ventilator machine, the gastroenterology doctors have their gastrointestinal bleeding stabilized with a proton pump inhibitor, the infectious disease doctors have their bacteremia stabilized with antibiotics, the orthopedic doctors pinned their broken hip, the hematology doctors are transfusing blood and platelets every day, and the patient is getting nutrition through an orogastric feeding tube- then everything can drift forward indefinitely.  The questions we have to ask ourselves as physicians are: will this patient recover? What will their quality of life be like if they do? In this way we can have informed discussions with patients’ families about decision making.

The problem is that many times the prognosis is far from cut and dry.  When a person has been very ill, we sometimes cannot tell how much function they will recover. Will they be able to speak, eat, sit up, walk again?  It will sometimes be weeks and even months before we have a full idea of their outlook.  These uncertain cases are the most difficult ones for us as physicians.  Other very challenging cases are ones in which we can clearly see that a patient will not recover from a devastating injury or illness.  Many times these patients are already very ill in the ICU and the decision is made to withdraw life support.  This is a complicated process in its own right that has many regulations in place that vary from state to state.

Each of these scenarios have a common thread.  They require communication, in spades, between the doctor and the patient and/or family.  This is one of the biggest barriers to making sure that people can have a good death.  Time.  To talk to your patients in the office about code status and living wills takes time.  To talk to every patient who comes in to the hospital in depth about code status takes time.  Time is something we doctors have very little of to spare, and it limits our ability to fully engage in these discussions with our patients.

Most patients I admit to the hospital have never heard the words “code status” before.  These are patients with severe chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure, diabetes, peripheral vascular disease leading to amputated limbs.  In other words- very sick people, but their understanding of their own illnesses is limited and skewed.  What does this mean in terms of their thoughts about death? It means that the 75 year old patient with COPD who is chronically on 4 liters of oxygen has not thought through needing to get resuscitated or intubated or the possibility of a tracheostomy- even though that would be a permanent fixture and he could be comatose on the ventilator for the rest of his life.  It means that the 80 year old patient with CHF whose heart pumps at only 10% of normal strength continues to want full resuscitative measures even though she states she never wants to end up “a vegetable.” If asked outright, both of these patients would tell you they would like to die at home with family around them. Both patients have high risk factors for impaired quality of life after CPR and for CPR to not be successful due to their severe chronic conditions; meaning, if they were to ever need CPR the chances of them recovering afterwards without any long term problems are poor.  CPR works well on people who are healthy and young.  As you age and the more medical problems you have, the less likely it is to be successful.  The more likely that if you need CPR you will wake up with more debility and problems that you started with, along with many broken ribs.

So how can we make a change?  Start talking about it, for one.  Death is something to be planned for and accounted for; it will happen to us all eventually.   The way to have a good death is to make your wishes known to your family and your doctor as early as possible. This also takes the burden of making decisions off of your family and lets them be at peace should they have to speak for you.  It is very hard on families to be placed in that position, and knowing that they are doing what you would have wanted eases the hardship.  We, as physicians, need to talk about it as well.  It is so hard to talk about bad diagnoses and prognoses, especially when there is a lot of uncertainty. I myself am still a young physician, and I am still learning.  I have had a couple bad prognosis conversations go poorly.  Even if you deliver the news as kindly, slowly, and deliberately as possible- it will be too overwhelming for some people.  There are people and families that will continue to hope for a cure right to the very end.  These cases are very heartbreaking to be a part of; the patient will almost always die in the hospital ICU after undergoing many tests and procedures and medical treatments that were futile in the end.

I recently saw a former patient’s family in the hospital.  This patient had come into the hospital in the last few days of her life.  Her family knew she had been declining, but they had not grasped yet that she was going to die quite soon.  She had advanced dementia and her nursing home had sent her into the hospital for severe dehydration and possible feeding tube placement. We all sat together and I explained to the family what was happening and that she was dying.  I asked them what she would want to do if she could tell us in that moment.  They all agreed she would want to be at home with her family.  Within the day our hospice team arranged this.  She was transported home and died the next day, surrounded by her husband, children, grandchildren, and great-grandchildren.  When I saw the patient’s family again recently, they thanked me profusely.  She otherwise would have passed away in a nursing home or at the hospital, and they were happy and relieved that they had the chance to spend her last day together at home. I accepted their thanks; I was glad I had helped her to have a good death.

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