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Less Is More
Aug 13/27, 2012

Quiet Caring

Author Affiliations

Author Affiliation: The Society for Patient Centered Orthopedics, Bloomington, Indiana.

Arch Intern Med. 2012;172(15):1129. doi:10.1001/archinternmed.2012.2138

During a walk about the oncology unit where I was receiving antibiotics for pneumonia, I encountered an elderly woman, her arm splinted and wrapped by a sling and burdened by intravenous and oxygen tubing. She was slowly and painfully making her way to the family lounge with her nurse and daughter. I helped them into the room, and then we all sat down. I asked her about her arm. She told me that she had broken her wrist in a fall and how upset she was to hear that she needed surgery for the fracture because all she really wanted was to go home and experience a little peace and comfort. She was leaving the hospital that day, and the surgery was planned for the following week. We conspiratorially spoke of our diseases: she had ovarian cancer with metastases to her liver; I told her I had undergone a second stem cell transplant—this one from my brother—for recurrent non-Hodgkin lymphoma and was now prone to infections, particularly pneumonia. She had persevered through debulking surgery twice and both standard and intraperitoneal chemotherapy, and she understood that she had little time left.

The planned wrist surgery upset me; I knew that, although such fractures are quite routinely surgically repaired, no evidence exists to show that such surgery improves outcomes in elderly patients. Furthermore, when the procedure, after years of use in older patients, was finally evaluated, a prospective study of displaced wrist fractures had shown no benefit from surgery compared with nonoperative management in any elderly patients,1 let alone those who are terminally ill. I informed her that there were always many opinions about how to best treat broken bones. I had already told her that I was an orthopedic surgeon, myself, but we did not discuss her care any further. We talked about the difficulty of being sick and the hope for better days, and then I left the lounge and wandered back to my room.

A few days later I was back at work, seeing patients in the office. My pneumonia had not been severe, but I was still receiving antibiotics through a peripherally inserted central catheter. I went into an examination room to see the last patient of the day, and I was greeted by my fellow hospital inmate and her daughter. They had come for another opinion regarding the planned surgery for her fracture. She had no pain, and while her wrist was swollen and tender, her hand functioned well. Radiography revealed a garden-variety Colles fracture. This was just the sort of fracture in which surgery could make the radiographs look better, but there was utterly no evidence that surgery improved symptoms or function in elderly patients, and, indeed, there was proof that it actually did not.

I came back in the room and told my patient that I believed her fracture would be best treated with a cast, and I saw no reason for an operation. Her eyes filled with tears, and she told me that despite all of the disappointments that her cancer had brought her, she still believed in God and had been praying that morning for something like this to happen.

I saw her in the office twice: the first time to put on her cast and the second to check that her wrist was doing well. I tried to give what comfort I could, knowing there was little else I could do. She died about 5 weeks after breaking her radius, well before the fracture could fully heal with either surgical treatment or my cast. Among other things, I remember quite well the softness of her voice, and I realized how hard it is to hear a quiet patient's voice when we are surrounded by such a cacophony of sounds: the manufacturer's representative's braying about his new, expensive plate and the need to keep up with the most advanced surgical technology, the surgical suite manager's praise and admiration when I book a heavy load of cases, the practice management consultants' chirpy remarks about the need to view patients as revenue sources and maximize the income streams that can flow from each encounter, and my anesthesiologist's thanks for keeping him busy with insured cases. A frail, dying, elderly widow's voice becomes so hard to hear against all the noises of contemporary private practice.

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Article Information

Correspondence: Dr Rickert, President, The Society for Patient Centered Orthopedics, 532 Ballantine, Bloomington, IN 47401 (jrickert1123@comcast.net).

Published Online: July 2, 2012. doi:10.1001/archinternmed.2012.2138

Financial Disclosure: None reported.

Funding for Less Is More: Staff support for topics research funded by grants from the California Health Care Foundation and the Parsemus Foundation.

Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older.  J Bone Joint Surg Am. 2011;93(23):2146-215322159849PubMedGoogle ScholarCrossref