Life is all about beginnings and endings. One of the biggest draws of obstetrics as a medical specialty is the fascination with the birth process as the beginning of life. The other extreme … well, let’s say in this particular place and time in history, it’s still something that catches people unaware. Too often filled with dread and loathing, we approach the death of patients as a foreshadowing of our own. Why else have we as doctors developed the reputation of squaring off with death? Beating him off with tubes and drugs and electricity, “No!” we shriek. “You can’t have this one yet!”
Let me share a secret with you: In spite of EMRs, PBMs, PQRSs, insurance companies, malpractice, legislation, and everything else you hear us bitch and moan about, we doctors care for our patients. And I don’t mean just in the sense of providing them with medical services. We care.
Over the decades, we come to know these people who have entrusted us with their lives. Many of them — for those of us who are especially lucky — we come to think of as friends. Friends who allow us the privilege of joining with them along this journey we call life; friends who trust us to do everything we can to keep them plodding along when its not yet their time, and those who trust us to ease their suffering at the end.
It’s been an interesting few weeks.
Two weeks ago, I got one of the most dreaded calls a doctor can get: My patient had come into the ER as a cardiac arrest. He was the same age as me, and he had simply dropped. No pulse; not breathing. No cardiac history; no medications; no chronic illnesses; no risk factors. Nothing. But his gym had an automatic external defibrillator (AED), a magical machine that delivered jolts of electricity to get his heart started again on the spot. Once. Twice. Five shocks from the AED. Two more from the paramedics, and another in the ER. Clear coronaries on catheterization; but progressed to cardiogenic shock; hypothermia protocol; aspiration pneumonia; transfer to tertiary center; left ventricular assist device. Suffice it to say, things didn’t look good.
But it worked.
For all the futile aggressive care we mete out to seemingly hopeless cases, this time it worked. After 10 days, I was talking with him on the phone in a regular hospital room. He was still pretty fuzzy on the details, as you can imagine; try freezing and thawing your brain and see how well it works right away. But it was him. And he’s going to be OK.
At the same time, there’s another patient. (There’s always another patient. No sooner do you hang up the phone and breathe a sigh of relief — then there’s another patient.) Nearing the century mark, he’d begun the revolving-door process of in-and-out hospitalizations for the last several months. CHF, pneumonia, NSTEMI, high-output cardiac failure from anemia; one thing after another. I’d been trying to broach the idea of hospice all along, but now he was wearying. This time he said yes.
I went to see him last week at home. He was having some pain and a little trouble breathing. He was reluctant to use the morphine on hand. I tried to reassure him.
This morning I took several calls from the hospice nurse as she struggled to keep him comfortable. It worked. Later this afternoon, I got the other call.
I’ve spoken before about the futility of discussing outcomes in primary care. Yet this should count as a good one. Passing peacefully without pain or suffering, with loved ones present. In its own way, as miraculous as birth. All that begins must end. A life well-lived; what more can any of us ask?
Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.
