Letting Go

Sometimes, death is easier for the patient than for the clinician. I met a wonderful 90 year old vet with a turn-of-the-century name (omitted for privacy reasons) who had metastatic end-stage cancer. He was receiving palliative care, but because of worsening pain, he decided to undergo a palliative surgical procedure. Although we sometimes think surgery is at odds with palliative care, there are times when the intent of surgery is not curative, but simply to make a patient more comfortable at the end of his life. This of course must be weighed against the risks and costs of a surgery so it's a rare event but certainly an appropriate one in some circumstances.

I met the gentleman in the ICU after the case. He was fairly hypotensive and so we resuscitated him, supported his blood pressure, and extubated him from mechanical ventilation. Boy, did he have a personality. He learned all our names (insisting on examining our badges), gave us sage advice ("To get to 90, have a glass of wine every day), and told us delightful stories from his nine decades of life. We grew pretty attached to him. When we talked to him about his "code status," he was quite clear - no heroic measures to resuscitate his heart and he didn't want us to "put that stick down his throat again." His daughter agreed wholly with his wishes. He told us he wished to have his body donated to a medical school. He had lived a wonderful life and made plans for his death. But day after day, he seemed to turn around, requiring fewer blood pressure medications and recovering from surgery slowly.

Unfortunately, at 90 with metastatic cancer, recent surgery, and a host of other factors, he had many reasons to have sudden decompensation. Twice, he had an arrhythmia that dropped his blood pressures and rendered him unconscious. The first time, medications brought him back. He returned to his usual personality, playfully bossing the nurses around. The second time, a completely unexpected cardiac arrest, was not reversible.

Surprisingly, this death affected he medical team more than anyone else. The daughter understood completely and accepted his passing. We, on the other hand, wondered what we could have done differently. Was there a medication we could have started earlier? A test we could have done? A quicker response to his arrhythmia? We wanted so much to have saved him because his personality was so endearing. He was so human to us, the epitome of happiness at age 90, and his death was a blow to ideals.

We had to remind ourselves that this was what he wanted, what was best for him. Instead of a prolonged death of suffering, he simply lost consciousness and passed. His wishes were upheld; he didn't have painful chest compressions or an undignified breath tube shoved in. He spent the last of his days joking with his daughter, telling me about his hobbies (he spent several hours a day on the computer corresponding), and assuring us he was happy and comfortable. Then, within minutes, he simply crossed the bar. In modern medicine, this was probably the most dignified, wholly appropriate, and somewhat rare kind of death.