Her name rolled around in my mouth like a smooth marble. It was the kind of name you don’t hear much anymore. Then, I looked at her birthday on her patient information sticker. The year was the nineteen twenties. It made me think back to the days of roaring twenties, flappers and the Great Depression. But in her case, it was real depression that eventually brought her to me.
Her husband had died. Her friends were long gone. She now lived in a convalescent home, with infrequent visitors. Her family was few and far between. Over the past few weeks, her already-declining health had begun to falter. She no longer ate at mealtimes. She didn’t wake for visitors. She didn’t move from her bed.
Her physical exam was disheartening. The outline of her bones protruded through her paper-thin skin and her abdomen was concave. Her mouth opened to reveal an absence of teeth and a desert-dry tongue. Her lab work was equally as dismal. This would not be a grand resuscitation. It felt like sliding down a mountain of ice: Starting any treatment at this point would be like clawing our way back up with our fingernails…making little progress, only to end up inevitably at the bottom.
But the son was determined to show me how much he loved her.
“I want everything done!” he cried.
And so on that busy day - like any busy day in any emergency department - I did what I would want a physician to do for me. I sat down across from him.
“I’m here to help your mother the best I can and it’s important that we are all on the same page with the goals of her treatment. Let’s talk about your understanding of CPR.”
Already well into her nineties, she had lived a full life – a happy life from what her son told me. We sat and talked and I asked him to tell me a little about her and how she lived, so I could better understand how she may want to die.
“Please help me,” he said. “I’m the only child and I don’t know what to do. I've never thought about living without her. I don't know if I'm ready...”
"But..." I gently said "...maybe SHE is."
He sat back in his chair, silent. I could tell he was thinking. I leaned forward, adjusting the blankets on his mother's bed, covering her hand with my own. I let my mind wander to the place it usually goes in conversations like this - what if this was my family? When he again met my eyes, I saw sadness and understanding behind the glimmer of tears.
We discussed CPR – cardiopulmonary resuscitation – which would involve vigorously pressing his mother’s chest if her heart were to stop. I told him about the statistics – about how only about 25% of people survive a cardiac arrest and how that number was a gross overestimation for his mother, who was elderly with many complicated medical conditions to start with. I told him about how if I was to start pressing on her chest in order to try to restart her heart, I would inevitably break many of her ribs, which could then puncture her lungs or internal organs and cause bleeding inside, causing further complications and more invasive procedures.
We discussed intubation, which would require putting a tube into her trachea and having a machine breathe for her. Because of her age and weakened immune system, I told him about the increased chance of her developing an infection from being on this machine – and of the low likelihood that we would be able to take her off successfully if we placed her on it in the first place.
We discussed how hard it was for him to be the one making this decision. And then, I held his hand as he signed the DNR papers.
As physicians, advocating for patients who can no longer advocate for themselves is one of our greatest responsibilities and privileges. We can fight death, but our successes in medicine should not be measured by how long we can retain life. Often, allowing a patient to die with dignity is a greater victory.
Physicians take an oath to do no harm, and from that day forward, our education is filled with ways to "fix" the problems we find. But along the way, we learn that every decision, every procedure, and every intervention has risks along with the benefits. Every action has a reaction. And sometimes, these actions cause more harm than good. We live in a time where technological advances are many - medicine has come a long way from the days of the Great Depression. But although technology has changed, our needs and desires as humans have remained the same. Among these: live and die with dignity.
The decision for families to let go of their loved one is difficult. I have never experienced a circumstance where it was easy. But some of the most beautiful deaths I have had the privilege to witness have been those that were on the patient's terms. Life is messy and medicine is even more chaotic. Both have the ability to sweep us off our feet and blindside us with devastation. The earlier we all start these conversations, the easier they are to continue.
So. Let's talk about Death.