They'd discussed it over and over again, the two of them. How he never wanted to end up on a machine. How he didn't want to be resuscitated, despite his long history of serious heart disease. How he wanted to go quietly if it was his time to go. They'd agreed, the two of them, that allowing a natural death was the right thing to do. He was a doctor, and she was his longtime companion and office nurse. More than most, they could see into the future.
But when she heard a thud and raced into the bathroom at home, she found him pulseless on the floor. Never mind the conversations, and to hell with the agreements -- nothing could stop her from calling 911 and starting CPR. Four days later, the ICU team confirmed her worst fears. His brain was irreversibly damaged from lack of oxygen -- "anoxic encephalopathy," we call it -- and it was time to call palliative care. My mournful task was to show her that the man she loved could be disconnected from the ventilator humanely -- no gasping for air, no struggle, no pain. A few hours after the ventilator was removed, he was transferred to our palliative care unit for end-of-life care.
The next day, I found her alone at the bedside, weeping. "We had an agreement," she said, "and I broke it. He wanted to die naturally and not be resuscitated. But I couldn't help it. I just couldn't see him lying there and not do anything."
There's no course in medical school that tells you what to do in a moment like that. But just as she felt she had to do something, so did I. "Look at it this way," I said. "If you'd followed the agreement to the letter, he would have been with you one minute and gone the next. Because you did CPR and called 911, you and everyone else who loves him have a little time to get used to the idea. A little time to start the grieving. He's not suffering now. What you did turned out to be a gift after all." She looked at me and wiped her tears, then nodded and thanked me. I went on to the rest of my rounds. He died a few hours later, surrounded by friends and family.
The traditional medical part of my job -- figuring out the source of a patient's pain, calculating drug doses -- is easy. The hard part is responding to whatever unpredictable and emotionally laden content comes my way. Five years from now, the family of a dying person won't remember or care if I used morphine or fentanyl to reduce their loved one's pain. But they'll remember every word I said and every gesture I used when their anguish and their grief overflowed, crying out for a response from those called to work at the end of life.