I gently rotated his arm as the beads of sweat formed on his forehead.  The pain came in waves.  His face contorted and relaxed in repetitive spasms.  I wondered if my exam was in vain.  The cancer had spread from his lungs to his liver and into his bones.  Once the blood stream had been tainted, the aggressive cells took flight and landed in various organ systems.

We already had the conversation.  I checked the boxes off on the POLST form.

X Do Not Resuscitate
X Do Not Hospitalize
X No Artifical Nutrition

Yet the hospice team had come and gone, and he refused to sign the papers.  He looked me forcefully in the eyes as he spoke.

You’ll take care of it!

But I was starting to feel his confidence was misplaced.  Day after day, I returned to the nursing home to find that our plan was failing to control his late afternoon pain.  Escalating his narcotic dose only provided incremental benefit.  Topical therapy, heat, and massage were adding little.

It was only after a week of failed attempts that he pulled me aside and quietly explained his hypothesis.

It’s the physical therapy, they’re pushing me too hard in physical therapy!

What? I almost fell off my chair. I couldn’t help my voice rising in frustration.

Why the heck are you doing physical therapy?

He took a deep breath before answering.  I could tell he was getting tired of my daft intellect.

Because the hospice people told me if I stopped doing physical therapy, I would be dropped from my Medicare days and would have to pay my own room and board.  And then the physical therapy people told me if they don’t push me hard enough, I will fail to make enough progress and will also lose my funding.

And like a blind man whose cataracts had just been removed, I once was lost but now could see.  He would live out his last hours struggling through futile physical therapy and in constant pain.  But he would labor selflessly to spare his family the financial burden.  He would expend more of Medicare’s resources than if he had just been covered under hospice, and would die sooner and in greater pain.

A tragedy based on administrative decisions made by non-clinical staff working for the government.  The pleas of those in the trenches have been ignored.

These silly rules are killing us, financially and physically.

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.