An overflowing kitchen table - when less is more

Big feasts or dinner parties for Vietnamese people is no dull affair. Cooking for others means cooking for at least 2.5x the others you have invited. If you have invited people to share a meal then it comes hand in hand with generosity and warmth – there is no compromise in this culture. My love of cooking probably stemmed from my grandmother and was nurtured by my mother. I have a memory of the scorching Saigon heat receding into the pink and orange-stained evening dusk as the sun settled into the sky with the crickets performing their symphony. The haze of the humidity still lingered in my grandmother’s house as the family gathered for dinner. This was in the pre-COVID era when travel was still a thing and my grandmother being alive was still a thing. As a vast array of dishes littered the dining room table and we gathered for dinner my grandmother would always turn to me first and tell me to start eating. “Go on my sweet girl, eat!” It was always the nourishment she took from seeing others content with the meal she had cooked that made me view cooking for others differently. Culturally, the elderly are also looked after differently as they age. Their children and grandchildren gather and take turns and try to facilitate as much as possible what the sometimes cranky older person wants as they become more dependent. This is not always easy. It is never easy to try to figure out what someone’s wishes actually are and what they truly want from their life.

Malee* was a lady in her 80s who I met following her admission to intensive care. She was hypoxic and unable to be managed on the ward. She had signs of severe right heart failure and an abnormal heart rhythm. She also didn’t speak a word of English. Now the medical encounter is centred around the history, which relies on both parties being able to understand and communicate with each other in some form or fashion. And no matter how loudly you yell at a person who does not speak English, they will still not understand you. We wave our hands and gesture dramatically at someone in desperate attempts, but at the end of the day, without a common language it is probably no better than hydroponics. (And yes, I appreciate the irony of this coming from someone who may well spend a large chunk of her career watering babies and hoping they grow up big and strong. And that doesn’t mean I believe in being liberal with fluid therapy for babies – I believe in formulas and calculations, I’m not some heathen.). Anyway, we had no real way of assessing Malee without her daughter there, who was able to interpret for us.

So we learned about Malee and her pain and her chest symptoms and her cognitive state. And day by day we tried to ‘optimise’ her – with medications, with fluids, with constant invasive monitoring. She was always grateful. She was grateful even after procedures that had caused her pain. I think it meant that she trusted us. What struck me though was how sometimes in very complex patients, we focus on targeting short term variables and that this focus ends up with lots and lots of clinical decisions being made and enacted – sometimes leading to a snowball-like effect. Things just keep getting done because we want to feel like we’re doing something. I wonder though, at which point we stop and consider whether we’re confusing a treatment with care.

I don’t have answers to these very big questions. People much smarter than me probably have them. What I do have is stories and a place for you at my kitchen table. Which will probably be laden with all kinds of foods served with a large helping of generosity. What I learned from my grandmother, is that more is more when it comes to serving those who come to eat at your dinner table. What I learned from Malee, is that sometimes we don’t know if more is more when it comes to prognosticating how well patients will do. A study performed in 2018 examining the impact on prognosis of early intubation in the elderly in the emergency department found, very surprisingly, that a proportion of those patients did end up being able to go home or to rehab. It wasn’t an entirely dismal prognosis as was hypothesised. Unplanned early intubation in the elderly did not always lead to death in hospital. Complex elderly patients can sometimes feel like their medical problems aren’t easily ‘fixable.’ Short-term variables, such as their blood pressure or heart rates, can be carefully targeted and titrated but what does their overall prognosis actually look like given their inherent medical complexity? When it comes to learning about complex medical topics, I often find that testing myself and seeing whether or not I can explain something by reducing the information to the minimum data points required to not lose the salience of the concept really highlights whether I actually understand something or not. Maybe it’s about less when we actually understand what’s going on?

I think I’m slowly learning that no matter how much you shower someone with much too much love or generosity or fluids or vasopressors it may not always be the right thing – no matter how well meaning the intent to do something (anything) is. It is much harder to do less. But definitely not much too much when it comes to fluids and heart failure because even I know that’s bad.

*All patient names have been changed and details omitted/changed for the sake of confidentiality

Proper readings instead of the drivel you just read:

Ouchi, K., Jambaulikar, G.D., Hohmann, S., George, N.R., Aaronson, E.L., Sudore, R., Schonberg, M.A., Tulsky, J.A., Schuur, J.D. and Pallin, D.J., 2018. Prognosis after emergency department intubation to inform shared decision‐making. Journal of the American Geriatrics Society, 66(7), pp.1377-1381.