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Medical Humanities

Goodbye

Reza Sedighi Manesh, MD

February 16, 2015

"I want to die," the patient wrote on a piece of paper. Ms. C was an elderly Chinese woman with widely metastatic breast cancer who presented to the hospital with sudden onset of shortness of breath.

I first met Ms. C two months prior when she was admitted to the hospital for a perforated duodenal ulcer. She was transferred from the surgery service to the medicine service after surgical treatment. When Ms. C and her family expressed a desire to pursue additional chemotherapy after she had recovered from the perforated ulcer, I was taken aback, given how frail and debilitated she already was. On initial reflection I reasoned that death is permanent and she, like many, would accept any potential opportunity to live longer. However, as someone whose personal and professional experiences have given me a more cautious perspective on aggressive end of life care, I worried that Ms. C and her family did not have a good understanding of the significant risks that were likely to accompany whatever small benefit she might get from another round of chemotherapy. This worry was compounded by a similar dilemma I recently faced as my family and I were making decisions for end of life care for my grandmother. After sustaining a hip fracture, my grandmother was hospitalized for the initial operation. She subsequently was immobile for one month, and developed sepsis secondary to a urinary tract infection. As she was being taken back to the hospital, I called my family and requested that they change her code status to do not intubate/resuscitate. Unfortunately, it was too late; she had already received chest compressions and been intubated. For three weeks she was neither alive nor dead but somewhere in between. She later died while intubated. I loved my grandmother and am saddened that her life had to end in such a fashion. This experience reminded me how painfully invasive and traumatic aggressive resuscitative efforts can be for patients and families. Sometimes, in these situations, less is more.

After two weeks, Ms. C was discharged to a skilled nursing facility in hopes of regaining enough strength to begin a new chemotherapy agent. I was not optimistic but wished the best for Ms. C.

One week after discharge, Ms. C returned to the emergency department in respiratory distress. It was serendipitous that I would be the admitting physician when she re-presented to the hospital. When I first laid eyes on Ms. C in the Emergency Department my heart sank. Despite being on high flow oxygen she was struggling to breathe. Her dedicated husband was at the bedside holding her hand, a worried look in his eyes. We (Mr. C and I) quickly had to make a decision about next steps. During her previous hospitalization she had been full code, wanting all possible medical interventions to sustain life. However, Mr. C was appropriately concerned that his wife was dying, and so another conversation about code status was in order.

I asked Mr. C what types of life-sustaining measures he thought Ms. C would and would not want in light of the recent changes in her health. He replied that she would not want to be intubated unless there was a chance of recovery to the state she was in prior to developing respiratory distress. I explained to Mr. C that it is difficult to predict whether she would make such a recovery if intubated but that I was not optimistic of her overall prognosis given the widely spread cancer. He knew that the medical system could keep her alive in the short term but did not want to delay the inevitable or prolong Ms. C’s suffering. He concluded that she would not want to be intubated or have chest compressions. Ms. C’s only wish was to say goodbye to her children and grandchildren.

As we were discussing Ms. C’s goals in the Emergency Department, my team began treatment to stabilize her. The chest radiograph revealed bilateral infiltrates consistent with aspiration pneumonia/pneumonitis, which quickly progressed to acute respiratory distress syndrome. We started intravenous antibiotics and bilateral positive airway pressure (BIPAP). The patient's oxygenation improved and she was transferred to the intensive care unit. I was taught that BIPAP is only useful in patients with cardiogenic pulmonary edema or chronic obstructive pulmonary disease exacerbations but I found another reason: to allow a mother to say goodbye to her children. Ms. C's children and grandchildren were driving in from LA.  When her family arrived we all gathered around Ms. C’s bed.

I removed the BIPAP to allow Ms. C to speak. Her daughter, son, husband, and grandchildren were all crying. Ms. C was smiling. I held Ms. C's hand and she held mine. In front of the room I asked, “Ms. C, what are your goals?"

She responded, in English, "my goal was to see my children one last time. I am ready to leave."

Unable to hold back my own tears, I wished her a restful night. I thanked her for allowing me the privilege to take care of her, and told her that I hoped she enjoyed her time with her family.

With an angelic smile, she said, "you have done a great job. Thank you for your care."

I didn't say "see you in the morning," because I knew I wouldn't, so I said, "goodbye." I left the hospital. Ms. C was started on a morphine drip and passed away in hours.

 

Acknowledgement: I would like to thank Rachel Elkin for her editorial assistance.


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