It is an immense heartache when patients die. It is a suffocating burden when they die alone. They are the completely solo patients hidden behind closed doors, the ones the nurses whisper rumors about, social workers feel sorry for and the doctors struggle to understand. The ones we all hope we will never become. I once had a patient, a 58 year old woman whose mortal body was cursed by years of vices and now alcoholic pancreatitis, the worst case I had ever seen, was devouring her ability to live. Her disease was fatal, her body weak, her family scarce, and her room silent. We badgered the next of kin, a daughter who was two states away. She repeatedly claimed she couldn’t make decisions for the woman we called her mother. She had not been raised by her, so our pleas for decisions fell on deaf ears.
It’s these lone patients that tug at my heart strings. Perhaps because three of my four grandparents died in hospitals and their final days were spent surrounded by dozens of loving and familiar faces. My grandma Flora was sent off with song and adorned in her favorite red lipstick, which we applied in her last moments. My aunt who succumbed to an iatrogenic case of cirrhosis died with hospice at home and more importantly with family. During her last breaths, her hand was held, her hair was brushed, and her check tenderly kissed. And when we removed my teenage cousin from the ventilator after he was declared brain dead from a tragic car accident, we waited for my aunts and uncles, cousins and siblings to gather around the bed hand-in-hand and we chanted one last prayer. This was the only way I imagined that people could die.
I wonder about those who die alone, how they lived their life in such a way that they find themselves in our hospital beds without a hand to embrace as they take their last breath, an ear to plead and pray to as they share their should-of and could-ofs, or a smile to embrace as their eyes close for the last time. I wonder about the mistakes they’ve made, the bridges they’ve burned and the regret they endure during their dying days. And then I met Joe.
Each morning the medicine team sits around a rectangular table on the second floor of our fancy new hospital and we are assigned new patients. It’s like a poker table. What hand will you be dealt? Are you going to get assigned the social admit who was only allowed entry beyond the ED doors because there wasn’t an available bed in the psychiatric hospital to combat his homicidal ideation? Or will you be assigned the guy who spit in his last nurse’s face? Even more frightening is the patient who is moments away from an ICU admission. All of these are 9s and 10s in a game of blackjack when you already have 18.
Joe was different though. His life up until that day sounded lovely. He had friends and family, but he had outlived them all, so he had surrounded himself with books and music. He had to pay extra for his corner apartment, so his antique collection could comfortably decorate the world around him. He was in his early 90s and his memory was crisp, not plagued with dementia. His thin frame seemed short and was exaggerated by the curve in his thoracic spine. The World War II veteran’s face was serious, the temporal muscles wasted away and non-cancerous growths of thickened and waxy keratin were scattered on his face. His islet cells produced insulin, his kidneys squeezed out creatinine appropriately, his lungs expanded compliantly and his heart pumped well. He described his only visit to a doctor as a begrudging attempt to walk-in to the Santa Rosa VA for tooth pain for which he was sent home with an appointment on a later date. He never returned, because he felt like his service as an Airmen had at the very least earned him one unscheduled walk-in visit. He raised his voice and proclaimed, “I ended up paying $500 at some other place to pull that tooth out.” And then on this fateful day, the dealer up above handed Joe a losing hand. His guts turned on him in the middle of the night and he awoke in agonizing pain. He showed up at our emergency department as sick as you can possibly be and still be able to speak intelligibly. He was in that sweet spot before the impending doom and there was my name right alongside his. We were assigned to each other.
I spent the next few hours figuring out what had gone wrong. I even had a confused radiologist call me up and confess her doubt in reading his films. It appeared his stomach had filled to the size of a large watermelon and creeped up through a hiatal hernia into the chest cavity. His esophagus was dilated and she couldn’t quite tell if there was a volvulus or some other obstruction at the level of the duodenum. This explained his hematemesis and intractable abdominal pain. I quickly reviewed the case with my attending, an intensivist, and a cardiothoracic surgeon. All agreed that he needed a nasogastric tube for decompression and an urgent trip to the operating room. He made several remarks about the price of such invasive interventions. “How much would that cost?” he said repeatedly. “I only have Medicare part B,” he added. I spent the second half of the morning trying to convince Joe that he would never pay a dime for this admission. I may have lied, but I knew his $500 dollar tooth extraction was clouding his thoughts. I also knew that he was lonely and tired. I convinced and convinced. He told me no, the nurses no, the attending no and the surgeon no. He had accepted his fate. He calmly took his cards in his hands and folded.
I made it my mission to not allow Joe to die alone. After all, he had ended up in Santa Rosa a few decades ago to bury one of his last living friends. He never left. I parked myself at a computer outside his room. I answered pages, wrote notes, and updated nurses all from within feet of his doorway. This allowed frequent check-ins. I peeked into his room every 30 minutes or so. Sometimes to see if he had pain, sometimes to make sure he hadn’t reconsidered the treatment options and sometimes to ask more about his life. He was a Tennessee native, who had spent a lot of time in New York. He actually had an older sister in Indianapolis but a stroke left her unable to communicate and comprehend. Apparently they had both drank from the fountain of youth. I felt that each time I asked about pain, he didn’t answer truthfully. One time, he tried to change the subject. “Joe,” I said, “are you comfortable, do you want pain medication?” He opened his eyes, looked into mine and asked, “are you an Indian?” This was probably in reference to my long braided hair. I told him no, but took the opportunity to tell him about Aaron, my boyfriend and member of the Ohkay Owingeh tribe. This Tennesse native said, “I think I might be part Cherokee.” So rather than ask about pain again, I made sure he knew there was analgesics available as needed. Several hours later, I was sitting at the nurses’ station crossing off to-dos when his nurse Rhonda called me to his room. “He wants to talk about that NG tube,” she said.
I rushed to his bedside. His eyes were filled with fear and in a confusing state, he said, “I just need to go to the bedroom and find my address book.” He shifted in discomfort, “It’s on the dresser and I have an old friend in Knoxville.” He was clearly panicking and I wondered if he had just realized his fate. Or maybe he had thought he would take his chances and gamble his way out of this. It was these emotions that swayed his previously steadfast decision. I highlighted the NG tube as the bringer of comfort, our last hope. Maybe if we decompressed the stomach, it would flip right over and correct itself. I ignored the rising lactate, the falling blood pressures and the racing heart. Somehow in my mind, I had a good hand of cards and I was going all in. He made me promise him that we would stop if the NG tube was smothering him. I gave him my word and proceeded to call the radiologist, since his condition was too fragile for a bedside placement by the nurses. I spoke quickly and I think the radiologist sensed my urgency, but still it took another 30-40 minutes before they actually wheeled him down to the fluoroscopy room. I took the opportunity to see a few other patients. I peeled myself away from his door and started to run some new information by my supervising third year. We were chatting when the overhead voice boomed through the hallways and shook my soul. “Code Blue in the Radiology Room. Code Blue Radiology Room.” I took flight. I sprinted down the hall, through the doors of Vineyard View, passed the residency office, down a set of stairs and into the first floor hallway where all things radiology are found. Since the ED is conveniently located within a dozen steps away, the room was already overflowing with humans. The radiologist I had just spoken to was paralyzed with fear. We made eye contact and I knew it was Joe. They were already bagging my Do-Not Resuscitate patient. The third year resident loudly proclaimed what everyone knew, but had ignored. “He’s DNR,” she said in one rushed breathe. A nurse held him tilted to the side to allow the gastric contents to flood out of his mouth. I assumed the position next to his bed and placed my hand on his body. He was warm, but lifeless. I listened to his heart, his lungs. I felt for his pulse. And when I could not confirm life, I escaped. All my chips were gone.
Since that day, I have reflected on why it is hard to lose patients who are elderly and with advanced illness. I wondered why it was so hard for me to let patients die, to allow natural death. Could I not forgive myself, if I had not offered every single option? Was morphine the only answer to this game? I felt guilty for not joining Joe in the fluoroscopy room, not holding his hand during his last moment and ensuring that he never felt smothered. I felt guilty for strongly encouraging the NG tube. Joe knew what was right for him and I didn’t recognize it until it was too late. I wondered about my unease with patients who died alone. I wondered if I would ever heal.
