My patients. In one room in the Intensive Care Unit of the hospital lies a 93 year old husband and father whose heart pumps against a nearly closed valve, in the process pumping fluid back into his lungs. With his pneumonia, low blood pressure and underlying kidney failure, there is only so much we can do. He is most likely going to die within the next few days or weeks. In the room next to him lay a 47 year old wife and mother of two young children who was diagnosed with an aggressive breast cancer that had spread to her liver and bones. One month ago she was a chubby, sprightly young woman, and now I struggle to see the face that desperately clings to her now prominent skull, with eyes that speak only the language of pain, and a tongue that utters the confused words of a woman inflicted with cancer and now infection. Next door to her another wife and mother, an 85 year old with a history of excessive mucus production in her lungs. She was brought in because she coughed up a large amount of mucus and choked, going into respiratory failure and then cardiac arrest. It was 30 minutes before she was brought to the emergency room and intubated (i.e. placed on a ventilator – a machine that breaths for you). When I examined her, her eyes were fixed, as were her pupils. She was being able to breathe on her own just a bit, but otherwise it seemed she had sustained tremendous brain damage from prolonged lack of oxygen. Finally, in the next room over, a wife in her 60's, her husband by her bedside. She is a woman whom the ICU team refers to as "the patient with more than 9 lives" from all the medical problems she has endured, including having to have been placed on a ventilator twice in the past week because of the cancer in her lungs and the effect of her essential pain medications on her brain's ability to control her breathing.
To the husband of the woman with breast cancer, who was a religious man and was still hoping for a miracle, we had to gently bring up the "possibility" of her not going back to being the same woman that he once knew - a reality that he had been desperately trying to ward off. Of course we knew her prognosis was grimmer than that. We'd seen it before. We knew what her end would be. And I could see in his broken eyes that deep inside he knew it too. I held back tears at seeing a man cling to a loved one who was so clearly slipping away.
To the husband of the woman who had suddenly choked on her own secretions, we explained that we were concerned she had suffered irreversible brain damage, and would most likely not recover. After agreeing to keep all her treatments going for another 24-48 hours to be sure, he clearly stated that his wife would not have wanted to be kept "artificially alive". We told him we'd place the order in the computer so that the doctors overnight would know that in the event that her heart stopped, we would not attempt resuscitation. He agreed. After decades of marriage to his beloved wife, he spoke solemnly, his lips quivering, "Well, all good things must come to an end." I walked out of the room silently.
Then the woman with more than 9 lives. She didn't realize how grim her prognosis was. We told her.
"Really?" she said, beginning to sniffle, "I... I thought I'd have more time. It's just too soon; isn't there anything else you can do?"
"There are... a few things, as I had mentioned, but as the cancer progresses our options become even more limited."
She turned to her husband, crying, "Oh Roger!" All Roger could do was hold her hand. Later, I saw him leaving the ICU with his head hung low, and it was as if I could see the turmoil of realization in his heart as he left.
My white coat is a symbol of science; a representation of precision, clarity and objectivity; a garment borne of test tubes and Bunsen burners. But the context in which this white coat exists is most often not a laboratory - it is the ebb and flow of a very organic life; full of love and fear and anger and tears and hope and sorrow. I may have spent years of my life studying the mechanisms, diagnoses and treatments of myriad diseases, but I never learned how to tell someone that their wife or husband or mother was going to die.
The first gentleman, Mr. Smith, whose lungs had filled up with fluid, had a daughter who spent most of the day by his bedside, smiling at him with tears in her eyes. He had a son who had flown in from abroad and sat calmly by his bed. He had a wife who was a strong woman, and who would explain to me that her daughter was being too emotional, and that while it pained her to think about it, she did not want him to suffer if it was his time. If it was his time.
I walked into the room on the 4th day of Mr. Smith’s admission to the ICU to check on his blood pressure, and to see if he was awake and responsive. He was neither. Three sets of eyes look up at me as I entered, all three of them filled with questions, all three of them telling me that they wanted to hear something that would give them hope.
“Hello doctor,” the son says, “how do you think he’s doing?”
I spoke softly. “Well, as you know we’ve had him on special medications to keep his blood pressure up,” I say pointing to the IV pole, four translucent bags dripping their contents into Mr. Smith’s veins, “and unfortunately his blood pressure is still very low. And as we had discussed yesterday, there’s a very real possibility he won’t tolerate dialysis to remove the fluid that has built up in his lungs with his pressures that low.”
“I see,” the son responded solemnly, the silence between spoken sentences was thick. His son went on, “and if we don’t do dialysis?”
“If we don’t do dialysis, the toxins that his body naturally produces that his kidneys would normally clear will eventually build up, and will ultimately affect his heart.” I didn’t feel it was necessary to be more specific.
The next question was coming: and what do you think will happen if we stop the blood pressure medications? Mrs. Smith seemed to look off in the distance.
“Why don’t we step outside?” I gestured to the door, looking at all three family members who quickly followed suit. We stood in a huddle, the three of them standing about three feet away from me, the nurses at the nursing station looking up at us knowingly, realizing that this was “the conversation”.
And then it came. The son with defeat creeping into his voice, “And what if we stop the blood pressure medications?”
I give my answer, a definitive one mixed with a degree of uncertainty, though I find it difficult to give uncertain answers to questions that expect clarity. “Well, eventually he will drop his blood pressure – it may happen right away, or after a few hours or even days – but eventually it will drop… and he’ll pass.”
Mr. Smith’s daughter broke into quiet tears, her body shaking with her silenced cries, her hands covering her face. His son looked at me with an understanding of things, and dropped tears of his own. His wife remained the strong woman who stated with a shaky voice, “I don’t think he would want to go on like this. I really don’t.”
I had just explained to a family that their father and husband would die soon. I had to make them understand that his death was imminent, and in a way, that they needed to accept that. Part of me hated myself for being the one to induce that look of understanding on the son’s face. He understood that his father’s time had come, and I knew in my mind that that was “good” in that it was acceptance of reality, but in my heart I felt terrible for having to do it.
The son spoke up, looking at his mother and sister. “Well, I just don’t think there’s any sense in prolonging this. I think… we should just make him comfortable.” His mother already nodding her head, they both looked to the daughter. She looked at them both, nodded her head ‘yes’, and continued to cry.
I placed my hand on the son’s back and lead them back into the room. They took their position beside their dying father and Mrs. Smith beside her husband. The blood pressure medication was stopped. Over the next two hours Mr. Smith’s blood pressure dropped as predicted, his heart rate slowing. The morphine drip ran into his veins to be sure he experienced no pain. Later that morning, Mr. Smith died.
* * *
I wasn’t there when he died. I left for the day, but before doing so peeked into Mr. Smith’s room and saw his family sitting next to his bed, looking back and forth between him and the monitor that showed the slowing electrical activity of his heart. I thought about saying goodbye, but was whisked away to another concern and right after that decided, without thinking about it, to just leave. All the way home I felt something was awry. I had convinced a family to let their father and husband die. It was clear that we were “artificially” keeping him alive and that he had no chance of recovery. It was clear that it was his time. I had not convinced them to actively end his life. I convinced them to let him die. My “rational” mind went through the whole scenario over and over again, each time convinced by the integrity of the act. However something deep within was having a hard time dealing with what I had done.
After reaching home, I washed up and prayed. I recited the Koran. I had time to clear my mind from consumptive, buzzing thoughts and see what it was exactly I was experiencing. What became clear to me was the following: to the vast majority of humanity across place and time, there is an embedded understanding of the sacredness of human life. It is in our natures, regardless of whether we behold ourselves as believers or otherwise, to have at a very fundamental level a sense of the magnificence of human life. To the extent that we are moral creatures, it need not be taught that to take a life is wrong, and the loss of life has a deep psycho-spiritual impact on us. Within that context I chose a profession whose very goal is to save lives and alleviate physical suffering, and I have striven and continue to strive hard in that regard. I suppose then that it is no surprise that I was shaken, as I had essentially acted as the catalyst in Mr. Smith’s death, though I had done nothing to cause it myself, and I was justified not only by society’s standards but of my own faith’s as well.
It occurred to me that as physicians we do this so often, yet there seems to be little recognition of the significance of the event. I am sure some of my colleagues spend time, perhaps at the end of the hectic day, reflecting on such matters; but it seems that more often than not we tend to just “get on with it” because that is what is required of us. And besides, “you can’t get all soft because you need to function” (which is the closest we usually get to any form of recognition). Yet, perhaps the significance of death and partaking in it should be recognized by us more, even if it is in the form of five minutes of meditation, reflection or prayer. It may be a way of keeping ourselves whole, by keeping our high-functioning cognitive faculties in touch with that more intuitive part of us that is habitually pushed aside in the name of efficiency, science, or whatever else. It may offer us a way to be remain in touch with our own humanity while we work, ultimately making us better physicians, rather than suppressing an essential part of ourselves inside hospital walls. In the very least, it would be a way of reminding ourselves that not far from the outer gleam of our bright white coat lies a human heart and soul, which is impacted by the vicissitudes of life and death.
