At War with Tobacco
Christine Navarro, MD
I arrived at their home after 2:00 pm. I didn’t realize how far they had to drive to see me. Mr. Hall met me at the door and gave me his usual bear hug. I was really pleased to be able to do a home visit with his wife.
Mrs. Hall became my patient at the urging of her husband. We met at the Urgent Care when he came complaining of chest pain. As Mr. Hall tells it, I reached into his shirt pocket and took his Camels, told him that the cigarettes were killing him and promptly threw them in the trash. He hasn’t smoked since. I hardly recognize myself as the firebrand he describes, but I had recently lost my dad to lung cancer and I can see how that may well have been true. He became a trusting and engaged partner in his own health. He also cut back the alcohol use and started to exercise more.
Mrs. Hall was not as fortunate. Tobacco held her in its wicked grip and she was unable to stop smoking until her emphysema was advanced. She had multiple hospitalizations for pneumonias, COPD flares and a chest tube. She became dependent on opioids and benzodiazepines, much to my distress. We negotiated back and forth on dosing, discussed the risks and benefits of medications. I was conflicted in advocating for her medications needs and discussed her care with the pharmacist and our CURES czar. She was a strong-willed, intelligent woman who skillfully advocated for her independence and what she needed from her physicians. Her pulmonologist and I always marveled how she continued to do so much while remaining on such high steroid doses – yet we were unable to taper due to symptom recurrence.
Later in her illness, her steroid side effects began to take their toll. She started to have classic Cushinoid appearance with puffy cheeks and a buffalo hump. Her skin began to tear and she needed continued wound care for the non-healing ulcers. Her husband dutifully brought her to her appointments and steadfastly took care of her with home health nurses as her mobility declined. For a while, her hospitalizations lessened and we celebrated two months of only clinic visits. But then things started to change.
We had multiple discussions of end of life care and what that meant to Mrs. Hall. She expressed her independence and desire to be home as a goal. Her husband was supportive throughout these discussions. Initially, she received Outpatient Palliative Services at home. After a more recent hospitalization, she agreed to hospice, but only after I offered to continue to visit her at home. Over the years, I have visited several patients at home with much success. This practice engenders trust in the hospice team and allowed our relationship to continue.
We had a wonderful visit. We talked about how the two of them met – him noticing her while she was out taking a cigarette break. We all found it ironic. I looked at all the family photos in the house, noted she had a large collection of angels and I rubbed her sore abdomen. We took another selfie for our album. I found great comfort that I was able to visit as a friend rather than as a medical provider. Yet, this visit was a gift to me as well, for I felt I honored that best tradition of what it means to be a doctor.