Richard was 69 years old, and he'd been in the hospital for 69 days when we first met. What had started as a routine operation turned into an up-and-down, lengthy hospitalization with three or four round trips from the ICU to the floor and back again. Along the way his wife, acting as his surrogate decision-maker when he was too sick to decide for himself, revoked his DNR status and implored the doctors to do everything they could. And they did, to no avail. Richard was on a ventilator a couple of times. He had several attempts to close his surgical incision, which had developed the nasty habit of popping back open -- dehiscence, we call that -- and setting the stage for infections that couldn't be cleared with multiple antibiotics. His kidneys were shot, and he appeared to be bleeding internally. Everyone but Richard's family -- and presumably, Richard himself -- realized that he was going to die in the hospital. The doctors and nurses in the ICU were hoping to stop what they thought was futile treatment and shift the focus to making him comfortable.
It was his surgeon, broken-hearted at the thought of losing his patient, who asked me to get involved. "Don't make things too complicated," he warned me. "These are simple, unsophisticated folks from the country. They don't understand much, and they're completely unrealistic about his chances for recovery."
Over the years I've learned not to make assumptions about what patients and families do or don't know or what they can or cannot understand. There are a few good rules of thumb about family meetings: Let the family do the talking. Explore what they already believe before delivering bad news. Make room for emotions. But every family meeting is different because every family reacts to serious illness in a loved one in its own way. The scientist Louis Pasteur said, "Chance favors the prepared mind." I try to go into family meetings prepared to be fully present, hoping to respond appropriately to whatever comes up.
I entered Richard's ICU room and, as is my habit, stood on the right side of the bed and put my right hand over his. He was awake and looked terrified. His wife and one of his five sons were in the room. I introduced myself and asked Richard how he was feeling. He answered, "I love Jesus I love Jesus I love Jesus I love Jesus I love Jesus."
This was not the response I was expecting. I didn't know how to answer, but I leaned forward to make better eye contact and said, "I'm not an expert, but I'm sure that Jesus loves you, too." Richard said, "I love God I love God I love God I love God I love God." All I could say in reply was, "and I'm sure God loves you, too." And then Richard said, "What have I done what have I done what have I done what have I done what have I done?"
The light went on inside my head. I leaned forward some more to get our faces closer together. "You didn't do anything," I said, still holding his hand. "You just got sick. And then you got a lot sicker than anyone expected. That's all. It's nobody's fault. You didn't do anything." Richard nodded and closed his eyes. His wife said, "No doctor has ever talked to him like that before," and she began to cry. We adjourned to the ICU waiting room, and within an hour the family had agreed to a new plan -- DNR reinstated, shift to comfort measures, transfer from the ICU, and pain relief. Richard came out of ICU and remained comfortable until his death several days later.
I told the story some time later, and a colleague asked how I'd known what to say to get the patient and family to a new, and more realistic, understanding. Dumb luck, I replied. I said that Richard had seemed uniquely ready at that moment to voice his underlying spiritual concern -- that he was being punished by God for some unknown transgression. I said that if I'd arrived ten minutes later or ten minutes earlier, I probably would have met the same resistance that other clinicians had previously encountered. I said I'd just gotten lucky, that's all.
It can be tempting to conclude that you have some special power, some extraordinary sensitivity that you bring to bear at moments of human suffering. And for those of us called to do this work, maybe we can become more attuned over time to nuances suggesting pain that's more than physical. If chance favors the prepared mind, perhaps it favors the prepared soul as well. On the other hand, it may be as simple as being in the right place at the right time, as elementary as asking a question. Dumb luck is still luck, after all.