Physicians, nurses, chaplains, and families writing on KevinMD about comfort, dignity, and quality of life in serious illness: hospice and why it is used late, the prognosis conversation, goals of care, symptom management, and what it is like to care for a dying patient. Most contributors work in palliative medicine or hospice, or have been the family at the bedside. For a maintained record of what physicians have said about dying and the decisions at the end of life since 2004, including the assisted-dying debate with both sides at equal weight, see End of life: what physicians say, in their own words.
I was covering for my partner over the weekend and saw his patient with end-stage liver disease, a consequence of decades of alcohol abuse.|
He was one of the most deeply jaundiced individuals I have ever seen. His mental status was still preserved. He could converse and responded appropriately to my routine inquiries, although he was somewhat sluggish in his thinking. It’s amazing that even after the majority of a liver …
“Why don’t you talk loud enough for the whole damn hospital to hear you?”
I’ve just greeted my eighty-four-year-old grandmother, and now this irascible voice has erupted from behind the curtain that separates us from whoever is sharing Grandma’s room.
The nursing assistant who showed me in glares across the curtain at the other inhabitant.
“You shut up,” she tells the person firmly, “or I’ll smack you with a bedpan.”
At first, you’ll question reality. You will hear your own words, but they’ll sound foreign — apart from you. The ground will still reassuringly push back against your toes when you walk out of the room, but you will wonder if they are your feet. Like in a movie, you will negotiate the world convincingly. Yet, you are an actor playing a part. It is not the real you.
I am working hospitalist right now. On Friday, a man in his 80s was admitted with difficulty breathing. He had a complicated history, including a heart attack at age 35 with all the subsequent sequela of heart disease. He had an abnormal heart rhythm and was taking a blood thinner for stroke prevention. In addition, he had scarring of his lungs (cause unknown).
When I was a practicing attorney, my colleagues and I would sit around at lunch, arguing about whose sandwich was better. Alone in our world of books and “right and wrong,” (as in “I’m right, and you’re wrong”), we spent hours creating problems to solve so we could make money. Lawyers — like many professionals — form their own little bubble, but unlike say, IT guys or architects, our bubble …
There was a lot about that place I didn’t want to see or hear.
The buzzing and whirring of ventilators; the loud call bells; near-dead patients; nurses running around with IV pumps and tubes dangling along behind them; the heart-stopping “Code Blue” warning; or the electrical sizzle of a patient getting shocked as someone screams, “All clear!”
Propelled in part by the unalloyed hopes I cultivated in medical school, I got through my internal medicine residency training largely free of questions about medicine’s limitations. Ailing strangers entered my life in the hospital and I helped them leave nearly restored to health. This was exactly the kind of physician I expected to be.
The news was bad. Mimi, a woman in her early 80s, had been undergoing treatment for lymphoma. Her husband was being treated for bladder cancer. Recently, she developed chest pain, and a biopsy showed that she had developed a secondary tumor of the pleura, the space around one of her lungs. Her oncology team’s mission was to share this bad news.
Mimi’s case was far from unique. Each year in the …
I waited intently as the board members rearranged in their seats and look up expectantly. Silence. I wasn’t going to let it be that easy. I repeated myself and paused again. This time a few tentative answers flutter up to the podium.
Hospice? Comfort care? End of life? Giving up?
Now this is something I could work with. I cleared my throat and smile broadly.
Alfred is 95 years old, and sits quietly in his wheelchair, rocking back and forth. His strength is gone, and his veins and tendons bulge through fair, translucent skin, stretched over muscles of long lost size and use. His greatest foe is gravity, which holds his lithe, bird-like form in the chair enough to cause sores on his hips, but only barely. It looks as if he might float away.
Laws that allow assisted suicide restrict the provision of “aid-in-dying” drugs to patients whose mental status is not impaired and who are capable of sound judgment.
Medscape recently featured a video interview of Timothy Quill, the palliative-care specialist and long-term assisted suicide activist. He is interviewed by the ethicist Arthur Caplan, and the two discuss the psychological evaluation of terminally ill patients who request physician-assisted suicide (PAS).
My first week on call, I got called in for a code blue. This patient happened to be the sickest patient on our unit. He had a tumor on his brain stem that was affecting his vision, hearing, swallowing, and breathing, so he had received a tracheostomy and gastrostomy tube as most palliative patients in his situation do. After a series of neurosurgeries, he was undergoing chemotherapy and radiation treatments. …
I would like to express my deepest condolences on the passing of your mother. She was a magnificent woman, and I had the pleasure of being her doctor for almost a decade. It was a pleasure. During our short visits, she regaled me with stories of childhood and often gently sprinkled in advice gleaned from years of experience. Even as she began to decline, we would sit together …
He was the last. Old and wizened, he counted down his final days, his final hours on earth. He lay in his bed, the rain drumming monotonously on the window. Night came. He pressed the button to call the aide. The aide appeared at his bedside. Every night, the old man had the same request. The aide went to the window and briefly pulled aside the curtains. He peered outside. …
As an oncologist, I have witnessed patients go home and heard later how they died there, surrounded by family and friends. I have seen others die in a hospital room, comforted by the care of the inpatient team even as they depart this earth. These are the ones that stick with me and what I think about when …
When patients and their families seek hospice care, they are thinking about how they will die. They want to be without pain, shortness of breath, loneliness and, above all, fear. They want to end their lives with those they love, in a place they know, with respect and support. They want control. They want dignity. We all know this, and try to provide it as friends, family and caregivers. Nonetheless, …
Today I saw a news story about Walnut, an 18-year-old whippet in the UK, who had his last “walk” on the beach with his owner who had asked social media followers to join them. Shortly after that walk, surrounded by hundreds of family, friends, and supporters (human and canine alike), Walnut was put down. His last moments were spent as near to Heaven on earth as his owner could create …
I dreaded Mr. L’s office visits. His mouth half vacant of teeth and his clothes reeking of hand-rolled cigarettes, he regularly demanded medicines he didn’t need. He was pushy and thankless. I frequently declined his requests. He stuck with me anyway.
Over the years he grew in orneriness. Divorced, childless, and unemployed, he declared one day that he was tired of living. He was reasonably healthy. He disavowed depression. Would I …
