Out of the Way with Ann Knapp, MD
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What is the opening disclaimer and premise of the episode?
At the Nocturinous, we are careful to ensure that all stories comply with healthcare privacy laws. Details may have been changed to ensure patient confidentiality. All views expressed are those of the person speaking and not their employer.
Doctors spend so much time focusing on diagnosis and treatment that it can be jarring when a patient declares that he wants to die. Especially when making that happen is easy as flipping a switch. I'm Emily Silverman and this is The Nocturneus. Stories about what it's like to work in medicine. In this episode, hospitalist Ann Knapp describes taking care of an elderly man who was ready to die and how that situation brought up feelings of confusion and self-doubt. After the story, we'll talk about how we make time to listen to our patients and how to approach the goals of care conversation. Here she is, Ann Knapp.
How does Ann Knapp describe her background and why she chose hospital medicine?
I'm a hospitalist and um in a past life I was a student of history and literature. And I like to joke with my patients and tell 'em I don't even have a science degree. And I'm your doctor. Um, admittedly that journey was fueled by a little bit of liquor and a sense of adventure. And um in a moment of delirium and in search of a purpose, I signed up for the MCATS and found myself in medical school. I was then sucked into residency. And then my soul was sucked out and I was spit out into the Sisyphian trudge that is a hospitalist. Um but really um one hundred years of solitude still lives in my heart. And I think it was my love of Faulkner rather than Osler that drew me to medicine. It's that narrative that ties us to the patient.
To humanity and the universe. It's that story that makes this journey worthwhile to me. So this is a story for you. And that morning when I met Mr. Redfield, um it was I was on telemetry, I was hit in the head with humility. And insanity. When I walked in the room, he I noticed he was a tall man, taller than the bed even. And it didn't fit him, and he was wiry and Awake and his eyes were on fire. More awake than any nine year old man I'd ever met.
What happened when Ann first met the 90‑year‑old patient who wanted to die?
And uh I'd had morning sign out, it was ninety year old man. Had two episodes of VTAC the night before his implanted defibrillator had shocked him back to life. А ту епизод с week before as well, and he said it felt like I was kicked by a horse. Anyway, I had prepared my scripted end of life conversation, you know. Oh, Mr. Redfield, um the prognosis is poor. You know, your heart is only working at ten percent. And we've tried every medication and you know, you're uh uh nine years old, the surgery is very risky. But when I saw him, I was intrigued. So I sat down for a moment to spend a little time with the man instead of the disease. He told me a story. That reminded me of my uncle Ross from Arkansas.
Uncle Ross, he grew tomatoes as big as softballs. And he kept a shotgun at the back door to guard the tomatoes from two legged predators. And like Uncle Ross. M he was a farmer. And uh he it was in no mood to wax poetic about the good old days. He said there was nothing good about 'em, they were hard as hell. And he'd been in World War Two and he said, that was a long trench through the muck. He also told me about his family. And his wife who had died And I started to realize that This man he was prepared to die. And then he said it. I'm done. I'm ready to go. I want to die. Okay. I said well, so much for my scripted conversation. Mister Redfield, you you can die.
How did the conversation about the patient’s goals of care turn into a request to turn off his defibrillator?
Oh gosh. I was thinking a can I turn that thing off? I think I turned off pacemakers before, but the defibrillator? Can you just turn that thing in his chest off? Mm uh uh well uh Mr. Redfield. Uh you can die. Well, let's do it. Um What do you mean? Well that thing in your chest, every time it shocks you, it's bringing you back to life. Oh well it feels like it's I'm getting kicked by a horse. I've had enough of it. Today. Today Um, let's see. Don't you think you should take the night to think about it? We should have a family conference and you know, I'll talk to your cardiologist. I was thinking, Where's the machine? Do I can I turn this thing off?
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Chapters
8 chapters
1
What is the opening disclaimer and premise of the episode?
0:00–1:03
2
How does Ann Knapp describe her background and why she chose hospital medicine?
1:03–2:41
3
What happened when Ann first met the 90‑year‑old patient who wanted to die?
2:41–4:32
4
How did the conversation about the patient’s goals of care turn into a request to turn off his defibrillator?
4:32–7:19
5
What ethical and logistical challenges arose when trying to shut off the implanted device?
7:19–11:49
6
How did the ethics consult, cardiology input, and family dynamics influence the decision?
11:49–16:06
7
What broader reflections does Ann share about technology, end‑of‑life care, and physician responsibility?
16:06–21:02
8
What closing thoughts and take‑aways do the hosts and guest leave listeners with?
21:02–28:53