Saturday, May 9, 2009

Hugs and Kisses

I met Molly when she told her internist she was tired of antibiotics and her orthopedic surgeon to take a hike. Well into her eighties, Molly had the litany of diseases common to many older folks --a bit of heart failure, a touch of kidney trouble, problems with diabetes that had shown up just fifteen years earlier -- but two things stood out. She didn't have a diagnosis of depression. And she had chronic pain -- lots of it. She'd been tried on a variety of pain medicines and, two years previously, had settled down with a fentanyl patch. This seemed to help, and she tolerated it without difficulty, but still she fell down and shattered her hip in multiple places.

Thus began the all too familiar downward spiral in the hospital. Surgery to fix her hip was postponed because she had diarrhea that had to be evaluated. In the meanwhile, she was placed in traction -- effective in reducing the pain from her fracture, but since it limited her ability to roll from side to side it made her back pain worse, which was why she had the fentanyl patch in the first place. Then her stool test came back positive for "c diff" -- Clostridium difficile, a nasty bug that's become a big problem arguably because we doctors haven't been smart about antibiotic choices. Now the surgery was postponed indefinitely while the infectious diarrhea was treated with IV antibiotics. But the infection didn't clear. Molly still had diarrhea as well as terrible pain from her broken hip. Her daughter Sara came to visit from out of town. They both told Molly's orthopedist that she didn't want surgery but did want to die. They told the internist they wanted to stop the antibiotics because Molly wanted to die. He felt torn between his desire to respect his patient's autonomy and what he felt was his professional obligation to treat her illnesses.

Molly's daughter Sara and I talked about the medical difficulties her mom faced. Sara was hoping that hospice might offer a way out.

This was the context when I went to Molly's bedside, pulled up a chair, put down the siderail and took her hand in mine. Those of us in hospice work are often trained in the "breaking bad news protocol," which outlines a series of steps to take. By sitting down and reducing our social distance, I'd taken the first step. The second step is to ask the patient something like, "What's your understanding of your health situation right now?" By having the patient talk about what she believes to be true, the theory goes, you can tailor the way you deliver the bad news you must deliver.

I asked Molly about her illness. I thought she would talk about her hip, or maybe her chronic pain. But instead she turned to me and whispered: "many bad much wasted time...much suffering." It was time to cast the protocol aside. I asked her, "What do you want?" Pushing her chin to the ceiling, she replied, "To go home." "Do you mean heaven?" I asked. She nodded.

There comes a time when you are faced with an impossible situation, and you have to decide whether you will help. Hospice is not about hastening death, and I do not work in one of two states in which physician-assisted suicide is legal. But those are abstract technicalities to a person in pain. So, with Molly's ice-blue eyes fixed on my face, I told her that the power to go home was a power she already had. She could simply stop eating and drinking. After a little while she was unlikely to experience either hunger or thirst. I assured her that we would be there for her. 

Her gaze softened, she whispered, "Thank you," and she pulled my entwined hand to her mouth and kissed it. In that moment I knew I had made the right decision. I excused myself to talk with Sara. She confirmed that this was her mother's wish and that she supported the decision. She asked, "Can I hug you now?" and I said yes.

Antibiotics stopped, traction went away, and pain medicine was adjusted. In just a few days, her face relaxed and her breathing easy, Molly went home.

Was this a hastened death? Well, it could be argued that neither Molly nor Sara would have necessarily figured it out on their own. But sometimes you are faced with an impossible situation, and you have to decide whether you will help.

1 comment:

  1. I can relate as I have many encounters similar to yours. I guess that wouldn't be a surprise as I also practice Hospice and Palliative Medicine. Thank-you for sharing that story as I have told the same thing to selected patients about not eating or drinking. People that don't understand our field may think it inappropriate but there are certain times, situations and people that this is an acceptable approach. I have also started a blog and would like some feedback. I have placed a link to your blog. The address is