The diet order, whether it’s for the patients to select for themselves or one that is most prudent and forced upon them, is often the smallest afterthought, but it frequently becomes the spark-less plug in the discharge engine.
To eat or not to eat:
- The patient can’t eat because of a procedure scheduled for tomorrow, but, oh, wait! They ordered food today and had a patty of sausage. The surgeon isn’t going to be happy. Or sometimes the patient is resuming a diet that had been held for whatever reason, but it must start with “clears” to see if they can tolerate it before moving on to soft, mechanical and then regular food. If the diet progresses too quickly, the patient may choke or get nauseated and the process starts over.
What to eat:
- The type of diet we’ve learned will lead to a healthier and simpler life. It may decrease the number of necessary prescriptions or effectively eliminate a disease. Or in the case of kidney disease, liver disease, diabetes, or hypertension, a diet low in phosphate or protein or carbs or sodium will help prevent further complications and make the management of the disease so much easier. Frankly, though, these diets are not easy or pleasant, and some patients rather starve than force bland fish down.
Diets are like medications, and they can sometimes do the same job as atorvastatin or metoprolol. Many people struggle for years adhering to a special diet. It’s in those last few months of life, however, when benefits bestowed by healthy habits lose their impact. The cost-to-benefit ratio is high. To be dying…as all of us are, I think we’d rather go down enjoying ourselves with milkshakes, french fries, and meatballs.
In my career I’ve worked in acute care, hospice, outpatient clinics, and even a while in a retail pharmacy. As a student intern working in a chain pharmacy, I encountered a patient dying to eat. Every month this thin man with a long, white beard walked up to the window and silently handed over a prescription for two bottles of viscous lidocaine compounded with some other ingredients. Sometimes he was by himself and sometimes with his son, but I never heard his voice. The lidocaine he bought numbed the pain caused by esophageal cancer and its treatment so that he could bear to swallow, whether it be a soft hamburger or a few sips of water. I can’t remember who stopped going to that pharmacy first, me or him, but I know I never saw him again after that summer.
My first clinical job after residency was at a large hospital with well-trained internal medicine physicians. One of my attendings was a pathologist turned geriatrician. She could see both the minute and the broad, the little things that could turn into big things. On rounds one day, a pleasant gentleman with dementia and no teeth widened his mouth with smiling eyes when we walked into his room. Our attending spotted a mild abnormality–a dried, white film coating the inside of his mouth. People with dementia often lose awareness and capability of performing self-care. Wetting his dry mouth had become someone else’s task. Our attending took a latex glove and pinched the film beginning at the roof of his mouth and removed it. I rarely get queasy in the hospital, but this did it, just a touch. The patient was happy with the result. He was always happy, it seemed. The man didn’t eat or drink much, but when he could communicate with family he asked for a McDonald’s vanilla milkshake and fries. At this point, the hospital’s cardiac diet was doing more damage to this amiable man’s spirit than good for his heart. “He can have whatever he wants,” declared our attending. The next day on our visit, a warm, salty, greasy smell hovered as we approached. He was there, smiling and sitting up in bed, with fries sticking out of his mouth. What else could he want.
There are occasionally those patients who we think are in denial. They have a very serious disease, cancer, that has brought them to the hospital. He had stomach pain and impatience. His wife sat in the window banquette, unamused by her husband’s grousing. She audibly hushed him as the team of white coats entered his room. Earlier before rounds, we discussed this gentleman. His first meal in two days had been a disaster. He hadn’t been able to eat before because of several tests we needed to perform. When he ordered spaghetti, he was disappointed by the meatballs, specifically the number of meatballs. There wasn’t much more we could medically do for this patient. His disease path was set, and intervention would be fruitless. “Sir, we are going to keep an eye on you today and hopefully send you home in the morning,” the resident stated in a bright manner. Sensing the annoyed demeanor of the patient, he followed up with, “and we’re going to up the meatballs. Doctor’s orders.” That’s all he needed to hear. Again he was able to live his curtailed life.
Today, the biscuits & gravy and bacon & eggs were on the menu for many. Patients who were admitted due to small bowel obstructions, electrolyte abnormalities, decreased appetites and depression, from whom we withheld feeding by mouth, were once again hungry and allowed to have a diet. Our team joked at the irony of fixing the mind and bowels only to wreck their arteries. Oh well, treating the soul is more important right now. Sometimes that’s the only treatment that works.