January 28, 2008

As Good as Can Be Expected

His last words spoken were "How's it lookin' doc?"

I responded, after a few seconds hesitation trying to summon the most appropriate thing to say to a man who likely would be dead within a few hours, "Well, I guess as good as can be expected..." And then I took his hand, gave it another squeeze, and he drifted off into that unconscious abyss between life and death.

He was 72. It seems appropriate to say only 72, because I think he should have lived much longer. He never smoked, or drank too much, he fought in wars and represented his people in the political arena. He had a colonoscopy every 5 years and a PSA annually. He took his pneumovax and routine flu shots. He did everything he was supposed to do.

Then again, he was 72. To me, that still seems old. It's more than 20 years longer than my dad lived, and almost 20 years longer than my dad's dad. But this guy had none of my family's bad genes, or bad habits for that matter.

This was the first time I had met him. He was lying on an ER gurney, gasping for breath but not particularly anxious or panicky. He was alone.

Three months prior he had gotten up to pee in the middle of the night and passed out. A doctor's visit followed the next day, and an xray led to a biopsy which showed metastatic lung cancer. He was given a prognosis of 6 months to live. Chemo and radiation wouldn't help him, and the cancer was too extensive to remove surgically. But he told me he never believed them; he thought he would beat it somehow.

For 3 months he toiled along, occasionally having some trouble breathing and coughing a little more, but doing reasonably well. No more doctor visits. No hospitalizations. He didn't tell his family - "didn't want to get them in a worry about nothing" he said.

But the night he came to my ER he started having a harder time breathing. He stayed home struggling for most of the night but when he collapsed to the floor in the bathroom and slammed his right chest into the commode he couldn't stand the pain and was having even more trouble breathing. When he arrived by ambulance about 4 am he was on a 100% oxygen mask with oxygen levels only about 90%, his heart rate was in the 140s, and he was breathing about 40 times a minute. One thing that I try to teach my residents early on is to try to differentiate the patient who is sick sick versus not so sick. This guy was sick sick - no doubt.

He was still coherent, and still competent, despite being critically ill. I sat down beside him, held his hand, got within inches of his face and talked to him while the rest of the ER staff started IVs and got EKGs and blood drawn.

He told me his story, as best he could with the little breath he had. He asked me to call his daughter and explain what was happening, and I did.

His labs and xrays and ekgs revealed to us that he had a heart attack within the last couple of days, that he had multiple broken ribs from the fall, and that his cancer was eating way at both lungs as well as his entire spine, his femurs, and his pelvis.

And so I had to talk to him, about what his options were and about what we could and couldn't do for him. I told him that this wasn't something that he could fix, and that he was going to die within the next day or 2. His daughter arrived.

We all agreed that we would do whatever we could to make him comfortable and let him die as peacefully as painlessly as possible. I ordered repeated shots of morphine and ativan, and we let him drift away.

Ya know, each person has their way that they need to deal with things. Some people won't understand that he wouldn't tell his family he was dying. They might think it was selfish or get angry. But everyone handles their problems uniquely, and there will never be, cannot be, a right or wrong way to handle many of life's scenarios. There can only be your way, his way.

In the end, he got what he wanted. His family never had to worry about him. And as I talked to them in the ER that night, I knew that they understood his decisions. He was intelligent, independent, and strong - and that's how he needed to be remembered.

I guess it went about as good as could be expected...

Thanks for joining me for My Daily Spin. [This story has been altered slightly to protect confidentiality]


IM Able said...

Thank you for this post. So clear, so purposeful. A moment of perspective for me while reading it.

IronMatron said...

I went to comment, but now I don't know what to say.
Thanks for the post.
I liked it.
I appreciated it.

Matt said...

Great post. I understand his decision, and it's probably one I'd make too. I have to wonder though if his family might start to feel a little hurt that they didn't get to say good-bye in the way they wanted. I lost my Grandfather without getting that chance, not for the same reasons, but I still deal with the feeling that I didn't get to say goodbye. Not many people do though. Guess it's all the more reason to let loved ones know how you feel before it's too late.