Several years ago I took care of an elderly woman in the ER.  She came in with a chief complaint of chest pain.  She came in via ambulance and by the time she got to the trauma bay she said she was feeling a little bit better.  She didn’t know she was about to die, usually people who are about to die look much worse.

She looked good, all things considered.  She was dressed elegantly, as if she had gotten primped before coming in.  In retrospect, she probably had.  My mother would never have considered going to the ER before she had taken a shower and gotten ready, it was just how she was, and this elderly beauty was clearly the same.

I took my normal history and physical, asking all the regular questions, making the occasional jokes as I have a tendency to do.  She smiled and I started a chest pain work up.  I rarely ask the DNR questions.  It is something that I should probably do much more regularly, but in a busy ER I often forget in the heat of the moment.  I have absolutely no idea what prompted me to ask them in this specific case.  Not.  A.  Clue.  But, for whatever reason, call it gestalt, hunch, or just plain luck, I asked the questions.

Me:  Ma’am, if your heart stopped beating, or you needed to be resuscitated would you want us to perform CPR or put a breathing tube in?

Her:  Son (when you are over 80, you can call me son, sonny, kid, or poopface for all I care), I have had a great life.  If it’s my time to go, just let me go.  I don’t want anyone banging on my chest or putting tubes in me to help me breathe.  I don’t want any medications keeping me alive.  If it’s my time, just let me go.

Me:  Yes ma’am.

So off I went to continue seeing patients in other parts of the ER.  I cannot recall the other patients I saw that night.  All I remember is that sometime later a nurse called me urgently back into her room.

You can guess the rest.

Her blood pressure was 56/24 with her heart rate racing.

Whenever a person is crashing hard, the room seems to almost magically fill with people ready to help.  I had four nurses, three techs, and an assortment of minions ready to medically kick ass and take names.  It was then that I did the one thing that never comes easily to an ER doctor.

I did nothing.  We let her go.

We did not start pressors.  We did not intubate her.  We did not start CPR.

Her blood pressure continued to decrease to nothing.  I turned off the cacophony of alarms.  We watched her die.

Could we have intervened?  Of course.  In this case we likely could have gotten her back.  But it wasn’t what she wanted.  She had been very articulate on that point.

We let her go.

In the ER, we see death more than most.  Usually patients come in non-verbal.  When a patient comes in unconscious and actively receiving CPR, distancing myself emotionally is easy.  Once I have a conversation with a person, it changes everything.

But this is true in all of life.  Once connected, we create a bond that sometimes can be hard to let go.  What can be dangerous, however, is if we cling tightly to the things that actually are doing us harm.

Letting go can be the hardest thing in the world.

Personally, I have a tendency to cling to painful experiences.

Letting go of the mistakes, embarrassments, and failures I find difficult.

I am not an introvert.  I can be boisterous, flamboyant, eccentric, and just plain loud.  But sometimes the loudest voice of all for me is the one inside.  You know that voice.  That dirty little jerk that hides in your mind putting you down.  That voice that whispers “you should be doing more,” “you’ll never really make it,” “you should feel bad about x.”

I can be my own worst enemy, silently berating myself and tearing myself down from the inside.  I know many people struggle with this as well.  Do any of you ever do this?  The world is more connected now it has ever been, yet I think people often feel more alone now than ever.  You can have 2,000 “friends” on facebook and feel so alone inside it hurts.

Sometimes the best intervention is just to let it go. Stop beating yourself up over past failures.  Let it go.  Stop ruminating about an ex, or a betrayal, or even that time where you did everything right and still did not get what you were hoping for.  We’re not really all that alone, no matter how much that sinister voice might whisper.

Let it go.

Let me know if you ever need a hug.

Rob Brandt is a an emergency physician and a columnist for ACEP News.  He blogs atRead more Brandt.