*Details in this post are partly fictitious*
She was a patient on the wards. What began with a simple chest infection, ended up to be aspiration pneumonia, when her stomach contents got into her lungs, compromising her breathing. Her body already riddled with dementia was weak and frail. And the acidity of the gastric juices had eroded, infected and inflamed her lung tissue. She was in a precarious state to say the least. Her partner was by her side almost all of the time, hoping for good news every time a doctor walked past her bed. It was clear very on that this was a difficult condition to beat. The nurses, the physiotherapists and I were all aware that this might be a battle that would end in defeat. It is not that we abandoned hope, but we knew what a dying person looks like. And she was one.
Despite the obvious warning signs, the consultant in charge of the wards that week was optimistic. He opted for active and aggressive treatment. "I am not like other doctors," he said to the patient's husband. "I will fight till the very end, and I am optimistic."
This statement did not sit well with me because it was a well known fact that this particular consultant was not a fan of palliative care. He believed in treating the patient all the way through to the last moments of life, because "giving up" (ie comfort care) wasn't an option. Despite concerns expressed by myself and other team members, this patient was to have regular suction, IV antibiotics, IV fluids, regular bloods on top of all his other medications. At this point, the patient was barely responding to pain, her oxygen requirements were creeping up and her blood pressure was in her boots. We actively treated her for two days, with little signs of any improvement.
Thankfully, on day 3, another consultant covered the ward. I made it a point to beg, "Please review this patient - I think she is deteriorating fast. I think it is time to keep her comfortable to maintain her dignity." This consultant did see the patient and agreed with my stance - but as he was only covering, he wanted a second opinion for a possible trial of assisted ventilation from the ITU team. I called ITU and after seeing the patient, the registrar came to me and said, "Your patient is dying. She has one foot already in the grave."
After getting the confirmation we needed from a secondary team, I insisted that we make this patient for comfort care. With an ok from the covering consultant, I stopped all her medications, wrote up anticipatory medications to keep her comfortable and together with the consultant, we informed her husband. Her husband was calm, but I could see it in his eyes that he was broken inside. I had a brief chat with him that morning and I did tell him that things were not looking good in efforts to forewarn him. But after this conversation that confirmed his greatest fears, as I turned to walk away, he said, "You knew this morning, didn't you?" I paused, and nodded slowly.
"I am so sorry," I said, "I wished circumstances were different."
"Thank you," he replied, "For telling me the truth."
My patient passed away peacefully the next day. She left this world with dignity - in her last few hours, she wasn't prodded with needles, she wasn't disturbed by nurses recording her observations. As far as we knew, she wasn't in pain. And that was so important for her and her family.
As doctors, we fix bodies. But sometimes, with the intentions of curing, we are tunnelled vision into believing that doing more is always better than doing less. The recognition of the dying is almost as important as the recognition of patients getting better. Admitting that nothing else could be done takes courage and humility. And as clinicians, we should be constantly aware of our mortal limitations and not make promises that we are in no capacity to make.
May God grant us all a beautiful end, just as he has graced us with beautiful beginnings. Ameen.
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