It is unethical not to be compassionate when you are a physician.  Treating people or their families poorly isn’t helpful to anyone in a stressful situation.  But a big problem exists there – ethics is not taught in medical school.  Then again, neither is compassion.  So where do you learn them?  Can you learn compassion, or is it something you just have?

Or don’t have?

She could have been anyone’s grandmother.  White hair, glasses, plenty of wrinkles.  But she was not your typical 91-year-old.  She lived by herself, she cooked for herself, and she still had a twinkle in her blue eyes.  She was not doddering and did not need a cane or walker, though she took each step slowly, carefully, deliberately.  She didn’t drive, but she still went food shopping with her daughter every week.  And somehow that was where it all fell apart.

She paid for her groceries and walked out of the store.  She either didn’t notice the curb or didn’t remember it.  It was only a few centimeter difference in height, but as she missed the step, her weight shifted forward.  Her daughter tried catching her but couldn’t reach her in time.  She struck the pavement, her face taking the brunt of the impact, and she passed out immediately.

She woke up as she was being transferred from the gurney to my stretcher.  “What’s going on?  What happened?” she asked.  I asked her name.  “It’s Catherine,” she replied, looking around the room, frantically trying to regain her bearings.  “What happened?  Where am I?”

I explained that she fell and was in the hospital.  She was a complete mess — her hair was matted with dried blood, her left eye was swollen shut.  There was a large laceration on her forehead.  Her nose was bleeding and angled to the right.  I suspected facial fractures but feared worse.

“What’s happening? Where am I?”

That’s when the perseveration started.  Repeated questions — a sure sign of a brain injury.  But how bad was it?  A concussion at least, to be sure.  But was that it?

“What happened?  Where am I?  Where’s my daughter?”

After assessing the rest of her and finding no significant injuries, we took her to the CT scanner.  I looked at the images of her brain quickly as they were taken, and there it was, my fears confirmed: a large subdural hematoma, bleeding in her brain.  Considering the amount of blood I was very surprised she was awake at all.  It was perhaps a survivable injury for a younger patient, but only with a risky and aggressive brain surgery to remove a segment of the skull and drain the blood.  But in someone this age …

I went out to the waiting room where her daughter was anxiously awaiting news on her mother’s condition.  She handed me a piece of paper with a list of her medical conditions, medications, and allergies.  I looked through it quickly, and one word immediately jumped off the page: warfarin, a very potent blood thinner.

Damn it.

I took a deep breath and carefully explained to her daughter what was happening, how her mother’s brain was bleeding, and how the bleeding would be difficult — if not impossible — to stop due to the blood thinner.

“Is she awake?”

“Yes, but probably not for too much longer.”

She looked surprisingly calm despite the devastating news.

“What’s happening?  Where am I?” Catherine repeated as we walked in.  The nurse was answering the question for the 8th or 9th time using a quiet, soothing voice, despite the fact that she was clearly getting annoyed.  I waited for a few minutes and answered a few more questions, then I excused myself to consult with the neurosurgeon.  As I was loading the CT images I told him Catherine’s medical history, about the blood thinner.  He took one look at her scan and laughed.  “She’s 90-years-old?  Ha!  Nope, not survivable.  Need to talk to the family.  She’s as good as dead.”

I knew that would be his impression.  A person that age with that size bleed on blood thinners is not going to survive no matter what we do.  “I’ll talk to them,” I said.  I didn’t expect his laugh, and I didn’t like his attitude.

By the time I got back to Catherine’s room a few minutes later, she was already much sleepier, but still talking.  “What’s going on?”  As I told her daughter the news, she nodded knowingly, clearly having figured it out already.  When I started to explain that surgery wasn’t an option, she stopped me and smiled sadly.

“Thank you, but she wouldn’t have wanted that anyway.  We’ve had many conversations about this with her over the past few years.  You know, just in case.  And she’s told us she would want us to let her go.  How much time do you think we have?”

I liked how she said, “How much time do we have”.  Most people would have said “does she have,” but she was asking how much time they had left together.  I appreciated the subtle nuance.  I told her maybe minutes, maybe hours.  But not long.  She took her mother’s hand, and I left them together.

I went back to see them a few hours later.  The rest of the family had arrived, and they all looked calm and peaceful, Catherine included.  She was unconscious, barely breathing, but comfortable.  Her daughter saw me, smiled, walked over to me, and gave me a wordless hug which said “thanks” louder than words ever could.

I don’t like watching people die.  It’s the opposite of what I do.  But sometimes it’s the compassionate thing to do.  Sometimes the right thing, the ethical thing to do is stop fighting.  Sometimes the person we really need to support is the one who is still here, standing at the bedside of the one who is not.

“DocBastard” is a trauma surgeon who blogs at Stories from the trauma bay.