The Last Day

Today I had to deliver a deeply painful message.

What do you do when you have to tell someone this: I'm sorry, but if we operate on you today, you'll die tonight; if we don't operate, you'll die tomorrow?

The surgeon who called me to confirm this devastating news for a patient was my friend Caroline Walsh, with whom I shared another tough, sad situation described in my Veteran's Day post.

Caroline was asked to evaluate an elderly woman with a terminal illness and a perforated bowel. The woman had a whole host of other conditions that made her what we, with our jargon, would call a "poor surgical candidate." From what Caroline, the ICU nurses, and the chart told me, this was someone who might not survive induction of general anesthesia. In fact, the clinicians who knew her best didn't feel she'd even survive the ride home in the ambulance unless she took with her the drug infusion that was maintaining her blood pressure. The woman had a DNR/DNI order in place.

When I arrived inside the ICU I met the woman's son and daughter-in-law, who was in tears. I spoke to them with Caroline, then was introduced to the woman's husband, who looked weary with grief. Then I went and spoke to the patient herself, a lovely, alert woman with short, wavy, snow-white hair and kind eyes.

I told her if we proceeded with surgery, I would have to intubate her and would likely not be able to remove the tube - ever.

I said the induction of anesthesia posed grave danger to her. Caroline had also already told her she might not survive the surgery or its foreseeable complications under the circumstances.

I told her I was concerned that if we proceeded , we would be unable to honor her wishes - namely, to spend meaningful time with her loved ones, aware of their presence, holding their hands, talking to them.

I told her that what Caroline and I wanted for her, and what she and her family also appeared to want, was for her to be comfortable, and to be able to share in her family's company, not to be hooked up to a ventilator and pressors in the hospital with Caroline and me.

She agreed.

Her husband, son, and daughter-in-law stood by, heavy-hearted, taking this all in. Her other child, a daughter, was on the way. Caroline and I promised to be available to all of them if they had questions, then took our leave. As I exited the ICU I hurled my protective gown and gloves into the trash with a bitter kind of resignation. Another patient for whom we could do nothing. Another family left broken-hearted.

She may have found her way back home with her family as I write this. Tomorrow, or the next day, she will die. As I drove home I had a jumble of thoughts in my head, none easy. Did I say the right things? In the right way? Why is it so hard to remain unruffled by emotions - as Caroline and I did our best to remain, as we were professionally obligated to do - when others are weeping in pain around us? Did the woman and her family feel supported despite our "professional" demeanor? If it were my last day on earth, would I want to know? What would I do? Whom would I want beside me? What do I want to see, do, experience, before that day arrives? How could I bear the pain of knowing I would never see my children's smiling faces, feel my husband's arms around me, again? Never another starlit sky, another warm fire in the hearth at Christmas, another passage of my favorite music, a moment of irrepressible laughter in a cozy home or over a favorite meal... Never again the scent of fruit newly opened, or the aroma of smoke from a candle just blown out...

I know this: the O.R. was not the right place for this lovely woman to spend her last moments, unconscious, bleeding out, with a tube in her windpipe and a bunch of stressed-out docs and nurses scrambling to try and help her survive. She belonged with her family, among those who knew her and loved her best, encircled by love, affection, and human comfort, and I hope that's where she is now.

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Photo credit: Sunset in Naples by Massimo Finizio, licensed by Creative Commons.