Too Fast

Alice was a feisty, independent woman with a terrible cigarette habit and lungs to match. Two weeks before she was referred to hospice, she was driving her own car and regaling friends and families with her strongly held opinions on anything and everything. Then she took a turn for the worse. Although exacerbations are common in chronic lung disease, this one was different. Alice didn't bounce back the way she had previously. Her adult children supported the decision to enroll her in hospice.

When I met Alice, she was in her bedroom. She hadn't been downstairs in over a week. She was working at breathing but still had the energy to laugh about political developments. (She followed the Democratic presidential race with energy and enthusiasm.) She was quite clear that she was dying and was most concerned about not feeling pain during the process. It was clear to me that she would likely be gone in a matter of days.

One of my harder jobs is offering a prognosis that's shorter than patients and families expect. Sitting around the kitchen table, Alice's family wanted to believe that they had a few months, or even a few weeks, to get ready for the loss of their mother. With as much gentleness as I could muster, I told them I thought she would die in a matter of days or perhaps a week or two. The body language around the table changed as we talked it through. In the end they accepted my recommendation that we start morphine, the hospice drug of choice for breathing trouble, right away. Almost immediately her shortness of breath improved, but she stopped eating and drinking and three days after enrolling she was unconscious. She remained comfortable with no signs of struggle and died the following day, just four days after signing up for hospice care.

Alice's death came too fast for her family. It almost always does. I spent two hours in her home that first day, hearing about her life, talking with her directly, and going over the plan with her children. More than anything else, I think a hospice doctor gives the gift of time. There's no other medical specialty, for the most part, that's willing to sit for long periods with patients and families to do the hard work of listening, counseling, and guiding. Any death comes too fast for everyone involved, but the one thing hospice doctors cannot be is fast. A physician's time is a gift at the end of life.