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A piece of my mind. A murmur of music.

A Murmur of Music WHY DID I CANCEL MY SURGERY?” MRS M REPEATED my question and stared at me through her black horn-rimmed glasses, the half-inch-thick lenses greatly magnifying her intense blue eyes. Along with two medical students and a resident, I was in Mrs M’s hospital room, meeting her and her daughter for the first time. We had selected Mrs M from a list of about 15 Medicare patients in the hospital that day who had also been in the hospital within the last 30 days. We were conducting a quality improvement project designed to determine if readmissions in this patient population are related to the previous admission, and if problems in the transition out of the hospital or other quality of care issues might have contributed to the second hospitalization. The complex older patients we see provide the opportunity to discuss clinical geriatrics as well as health system approaches to improving quality of care. Mrs M’s readmission was indeed related to her previous hospitalization for congestive heart failure associated with critical aortic stenosis. But there appeared to be no care quality problem that had led to her being back in the hospital. The daughter, with whom Mrs M was living, assured us that her mother took her medications faithfully, avoided salty foods, and had seen her primary care physician and cardiologist within a week of her previous hospital discharge. “I know my heart valve is blocked and that the only way to correct it is surgery,” Mrs M related in a matter-of-fact manner. “When the doctors discovered it just three months ago, they explained everything. My daughter and I decided to see how I did without surgery. I’m 92 years old and I’ve lived a good long life. I want to live my remaining time with as good a quality of life as possible, but I don’t want to be a burden to my daughter.” Readmitted to the acute hospital for the second time in two months for recurrent congestive heart failure, Mrs M had been scheduled for a valvuloplasty that morning. “My cardiologist sent one of his partners in yesterday to talk to me about the surgery. It was the first time I met him. He was abrupt and told me I needed the surgery or I would die. I didn’t like him, so I canceled the surgery.” Sitting in a chair next to her bed, I nodded and said, “I understand.” The students and resident stood by the bedside obviously taken aback by her brutal honesty in discussing her encounter with the cardiologist. “Would you mind if I listen to your heart?” I asked after a moment’s pause. Upon hearing the classic harsh, loud murmur of aortic stenosis, I asked Mrs M if the students could listen. “Why of course, they are here to learn.” I was grateful, because it is one of those physical signs that you love to demonstrate to eager third-year students on their medicine clerkship—one listen, and they remember what critical aortic stenosis sounds like for the rest of their careers. As they finished listening, Mrs M looked up at me and asked, “What does it sound like?” Taking her cue, I put my stethoscope in her ears. And then it happened. Almost exactly as I placed the stethoscope on her left sternal border, my phone rang with one of those classic cell phone tunes. I saw Mrs M’s eyebrows rise way above her eyeglass frames. “I hear music!” she exclaimed without skipping a beat. Indeed, she had what I learned in medical school to be the “musical murmur” of aortic stenosis. And I was thrilled to pass this on to my students in such a profound, serendipitous, and humorous way. But it really wasn’t the cardiology lesson that was the key geriatrics teaching for the afternoon. The students and resident got to see first-hand the complexity of hospital readmissions of elderly people. Many such occurrences are avoidable and provide opportunities to improve care and reduce unnecessary hospitalizations with their attendant morbidity and costs. Health professionals trained in geriatrics are critical to capitalizing on these opportunities. But it won’t be simple, as Mrs M’s case illustrates. Some patients have chronic diseases that deteriorate despite the best of care. I’ve learned from many patients and their families that accepting palliative care over invasive surgery for endstage disease is not an epiphany, but a process that takes time, information, and trusting relationships. Mrs M chose her path thanks in part to the encounter with her cardiologist’s partner—an unpleasant experience that ended up being a blessing in disguise, because it helped Mrs M to make the decision she felt was the right one for her. Would the surgery have improved Mrs M’s quality of life or made it worse? That question is difficult to answer. Valvuloplasty is a palliative procedure, and not without complications. Unwittingly, by giving her an ultimatum of “have surgery or die,” the cardiologist opened up a third option for Mrs M: to live the time she had left on her own terms. Our visit and the frankness with which Mrs M voiced her concerns helped me and my students, and most importantly, Mrs M and her daughter, understand that in this case, the decision made was one that best satisfied her wishes and those closest to her. And that was music to everyone’s ears.