Friday, March 14, 2008

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.


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


Anonymous said...

I read your blog regularly, but don't usually comment. This post, however, was especially moving for me given that we just experienced a loss in our family.

I can understand your frustration that you "could do nothing" for this patient, but if her family was anything like ours, then you did, in fact, do something very important for them.

I have no doubt that the knowledge and professionalism you and your colleague displayed was extremely reassuring. Together, you enabled a family to spend their remaining time together confident that the best decision had been made regarding your patient's care. This will continue to provide comfort to them even after their loved one's passing.

Thanks for sharing your stories with us.

T. said...

Ericjay, I am deeply grateful you took the time to comment here. As is normal in situations like this, I've been over the experience repeatedly looking for things to second-guess...then second-guessing...then wondering...then hoping...then back to re-living...and so it goes. Your words give me hope that in trying our best we were able to help in some small way, invisible to us but real for this woman and her loved ones. Thank you for reading.

Anonymous said...

Your honesty with the family and your willingness to explain things to them in a truthful way is impressive. There is no easy thing to do in a situation like that. But simply telling the truth and laying it all out clearly probably made all the difference in the world for them.

T. said...

Lord, I hope it did. I truly hope it did.

I can't help wondering if it all would have played out differently if she had been at a large academic center, a more "aggressive" place with a bigger blood bank etc., instead of a small community hospital, where we had the time to sit with everyone and listen, really listen , to what was most important to them and also communicate what was crucial for us to communicate...(Though I must say the ICU docs where I trained were really great about making these efforts.)

I just spoke to "Caroline" and I think the woman is about to leave the hospital and go home to her own bed and a hospice nurse, with her husband and kids around her.

Anonymous said...

I, too, read your blog regularly. Just over a week ago I lost a close friend to cancer. It was over a number of days that the family spoke to the doctors about the "real" outcome of the cancer treatments. They also talked about the quality versus quanity of life. After much thought and prayer my friend made the decision to go into hospice. Between her doctors, nurses, and then the staff at the hospice I don't think I've ever met such caring people. Every last one of them were feeling the pain as much as the family. And then to have the staff be able to help the family and friends through the transition...

Those last 12 days were worth every moment we had left with her. The staff cared for her and made sure she had her dignity about her by combing her hair and keeping fresh gowns on her. They were able to manage the pain but keep her lucid enough to talk, laugh, and joke with us. She was able to say goodbye to her parents in Ireland, clear some issues up with her sister. Sometimes we just watched her sleep. Other times she seemed to just gaze at us as if memorizing our faces.

I'm still so sad but I felt that I was able to say goodbye. I heard that her primary physician sat with her close to the end. The family really was supported by this gesture.

The idea of dying with tubes and pain scares me. If I had a choice I would take an hour to say goodbye than days of pain and suffering. Ironically, we have just found out that my mother-in-law could be in hospice within the month.

Thanks for sharing. Many of your posts have made major impacts on how I think about living and dying.

T. said...

Dear celloluv, I am very sorry for the loss of your friend and for the pain of your mother-in-law's situation. I thank you from my heart for sharing your experiences here, and for taking the time to stop by and read every once in a while.

Lisa Johnson said...

As sad as this situation was, I'm sure that she and her family were so grateful to you and for you. The compassion and care that you show here really touches my heart. It really means a lot.

shuna fish lydon said...

Thank you for writing down your experience and thus the experience of a family's loss, for that loss could be any of ours.

From my own experience I will say that it was with those doctors, nurses and hospice people who told me and my family the truth, in all their humanness, that I placed my heart and my trust.

What you do for a living is beyond my grasp, my reach and my capabilities. from reading, and now the tears coming, I will say that although I cannot tell you if you did the right thing, said it the right way,

it's not about being right,
it's about heart.

T. said...

Shuna, thank you. Tears here too as I read your beautiful words.

Anonymous said...

Like all your other readers, I find it so easy to place myself in the shoes of the grieving family, and I'm grateful to the docs in my life who have shown the lovingkindness to my family that you have in this story. And like the folks posting here, I find it painful to try to place myself in your shoes.

Reading this post on the eve of the Triduum, I look to my own grief in life and in stories like the one you've shared, and I try to remember that we are supposed to be an "Easter people." It should be wonderful to live in the light of a risen Christ, especially at this time of the year when the Church makes the story so real for us. Still, I struggle most of the time to find that light, let alone to bask in it and forsake my own struggles. Perhaps that's why we have such a beautiful run up to Easter in the Triduum.

I hope you find comfort in Holy Week this year and that we both find -- and hold on to -- the light of being an Easter People.

valleygirl said...

I have not had a chance to read your blog in sometime. Reading this post made me realize how much I'd been missing with your writing! This was such a poignant post. I am impressed with how you handled the situation. I can't say that other doctors I've met would have been as thoughtful and compassionate, yet informative.