Saturday, March 24, 2012

Death cookies

One aspect of medicine that I really enjoy is that no two days are alike.

Every day I see new patients with new problems and old patients with old problems.  And don't forget the old patients with new problems of the new patients with old problems.  You get the picture - nothing is ever the same.

This is especially true in internal medicine, where the spectrum of disease we treat is quite broad.  In one day, I can treat anything from a pesky wart to a life-threatening pneumonia in the intensive care unit.  I can help with your chronic back pain (ooooh how I loathe treating chronic pain) or treat your heart attack on the medical ward.  

Specialists may disagree, saying that there is a large spectrum of disease within their respective disciplines, which to an extent is true.   But get them out of their specialty, and they are pretty much useless.  Next time you see your cardiologist, casually mention the rectal bleeding that you've been having and watch him squirm - something akin to 'you should talk to your internist about that one' will flow naturally from his lips.  Or if you really want to see someone get uncomfortable, tell your neurologist about the vaginal discharge you are having.  Whoa!  No thanks!  They'll punt that one back to me in a hurry as well.  Point being that we have to know something about everything, which makes each and every day new and exciting because, like Forrest Gump said, you never know that you're gonna get.

For better or worse, administrative policies and procedures seem to change daily as well.  Some of them are for the better, and some of them are clearly for the worse.  This is not unique to medicine - you all know what I'm talking about.  It seems we can't go more than a month without some big change to our EMR that throws us all for a loop (I love you and hate you at the same time, technology).  And then there are the changes that are, well, neither good nor bad, but are just more changes.  I don't mind these so long as they don't move my cheese too much.  But there was one particular change that I noticed last week that really made me stop and think.  I'm still not quite sure what I think about it.  You decide for yourself what you think and let me know.

I had a patient that I was caring for die in the hospital this week.  She was in her 40's and had all of the sequelae of many years of poorly controlled diabetes - retinopathy, nephropathy and now on hemodialysis, vascular disease with below the knee amputation of a lower extremity, coronary artery disease, and so on.  If that wasn't enough, she was diagnosed with colon cancer 5 years ago and had 2 recurrences that were successfully treated with surgery and chemotherapy.  Just last week, however, she found out that the cancer had recurred for the third time.  Some people just have no freaking luck in this world.  As an old professor once told me, "Sometimes I think the Good Lord goofed."  You all know someone like this - it seems that all of the bad stuff happens to them.  Anyway, she started on chemo 10 days ago (third time's never a charm for chemo) and ended up terribly dehydrated from the nausea and vomiting.  On top of that, her immune system was so devastated by the chemo that she had almost no white blood cells circulating in her system and developed a terrible abscess and cellulitis of her arm.  She ended up in the hospital on my service with sepsis.  

This hospitalization was the last emotional straw for this poor woman.  She was tired of living.  She wanted to be treated for the infection, but didn't want any aggressive treatment.  On her second day of hospitalization, her already broken body succumbed to the overwhelming infection and she passed away peacefully.  None of us were surprised at the outcome and even expected it.  Her loving family was thankful for the care that she received.  They were understandably sad - yet relieved at the same time that her suffering was finally over.

Now here's where it gets a bit interesting.  I got to the hospital at 7am and learned that she had passed away sometime in the night when I wasn't there (on-call physician handled everything overnight).  The family was already gone by that time, so I didn't go to the pod where here room had been.  If I would have known that there were fresh cookies there, maybe I would have stopped by.

What? Fresh cookies?  You mean one of the nurses happened to coincidentally bring in a batch of cookies for everyone on the pod to share?  Ummm, no.  

A few hours later, I was chatting with colleague about this patient and she told me that she happened to be on that very pod earlier in the morning when she came in to work.  She noted that many of the nurses were eating cookies and asked who made them.  "Oh," she was told, "these are from the cafeteria.  They're the death cookies.  Do you want one?"

The what?  Death cookies?  Did I miss something?  Is this a joke?  Well apparently it isn't a joke, but I did miss something.  The hospital (recall the concept of constant change) has now decided to provide a batch of warm cafeteria cookies to family members any time a patient passes away in the hospital.  Yes, you heard that right.  Maybe it's been around for a while and I just never new it, but this was the first I have heard of it.

They've been around now long enough to be known by the nurses as death cookies.  I cringe a bit every time I even write that now.    

Have you even been present when someone passes away?  It's a very unique circumstance - one that I can't even really compare to any other that I've had.  For me, it's almost a sacred moment.  It's so much emotion wrapped into a brief moment.  If you've been through it, you understand.  It's hard to describe accurately.  But what I can tell you after seeing a lot of people die is that I don't ever recall craving sweets after witnessing a death.  In fact eating is about the last thing you want to do.  Maybe I'm abnormal in that sense, but I haven't ever seen anyone bust out the picnic basked after seeing someone die, so I must not be that abnormal.  

But cookies?  That just seems so weird!  We don't give them out on admission.  I've never seen anyone get them after a successful surgery.  I don't even think that my wife got any after the birth of our children!  So what's so special about dying in the hospital that warrants fresh cookies?  

The cynic in me instantly wondered if it wasn't some crafty policy drafted up by the risk management department.  Maybe studies have shown that lawsuits were significantly decreased by offering warm cafeteria cookies to families within one hour of death (p value < 0.0000001).  Perhaps I need to stay up to date with current literature better!  

Then I rebounded to the opposite end of the spectrum, thinking that maybe it was the idea of some sweet, well-intended nun who made it her life's mission to help loved ones in their grief.  Maybe she's well known for her homemade cookies.  Maybe they are symbolic to some particular faith. 

Then I remembered patient satisfaction scores.  If you aren't aware of these then you might be surprised to find out that hospitals, starting this year, will receive financial incentives from Medicare if they outperform their peers with better patient satisfaction scores.  

Am I jaded and cynical for even thinking that this could be the impetus behind the death cookies?  Surely money has never enticed anyone to do anything strange in this world!  But could they really be so shallow to think that no one would notice if this wasn't done in a genuine manner?  Then again, if that was the real purpose behind it, why don't they give unhealthy, yet satisfying treats to all patients when they are discharged home?  Omg I can't stand it anymore - will someone just tell me the truth and let me lay this to rest?  

It really doesn't bother me that much -  I tease simply for dramatic effect.  But at some superficial level I'm still curious as to the etiology of the death cookies.  I'm glad that the nurses enjoyed them.  I'm not sure that I even would have eaten one so early in the morning - especially after my usual morning breakfast of oatmeal and a big frosted donut (I love you whoever created donuts).  But I'll never look at those cafeteria cookies the same anymore, that's for sure.  And maybe with enough persistence and investigative fervor I'll find out the real story behind them.  And maybe it will be enough to restore my faith in hospital administrators - or even mankind - or maybe even in myself.  


  1. I truly am enjoying your blog. You don't happen to practice in Florida, do you? This totally sounds like something that my hospital would do to raise their scores.

  2. WTF. Warm cookies are something a real estate agent offers to people who are walking around looking at the house he or she is trying to sell. They shouldn't be offered to the bereaved just after their loved one has died.

    I was at my 60 year old mother's bedside when she finally succumbed to a cancer. It was far from a peaceful death. If, after her passing, someone approached me and offered me a plate of warm cookies, I would have punched their lights out.