The ICU called me to participate in a family meeting. An elderly Russian woman had come in for a routine surgical procedure. Now she was fighting for her life. She'd had a cardiac arrest from which she was resuscitated, but the strain was too great for multiple organ systems. Her lungs and kidneys were failing. She had developed a paradoxical problem in which she was bleeding at the same time that her blood was clotting. ("Disseminated intravascular coagulation," or DIC, is its mouthful of a name.) Her husband and two daughters gathered with the medical team in the conference room to review her situation.
Treatment for the clots would make the bleeding worse, the intensivist told her family, and trying to stop the bleeding would accelerate the clotting. She almost surely would never come off the ventilator, at least not for a long time, and that would mean "trach and PEG" -- a hole in her windpipe for the breathing machine, and tube through the abdominal wall into her stomach for artificial feeding. The alternative, we all said, was to shift the goals to comfort care. As the palliative guy in the room, it fell to me to describe what that would look like -- weaning from the ventilator, using morphine-like drugs to ease the work of breathing and relieve pain, probably stopping dialysis, and preparing emotionally as best they could for her death.
Her older daughter, whom I'll call Lena, spoke passionately about her mother's background. Born a Jew in the Soviet Union, she'd overcome hardship and discrimination to become a physician. She emigrated to America and struggled to raise a family and make ends meet, all the while dealing with several chronic health problems that had required multiple hospitalizations. "She is a strong Russian woman," Lena said in her own heavy Russian accent. "I understand what you doctors are saying, but I think my mother is telling me that she wants to keep fighting." Lena looked at me and said, "Doctor, let me ask you this: what would you do if it were your mother?"
Physicians are often advised to avoid or minimize personal disclosure. The line I was taught to say in response to a question about my personal life was, "I don't see how knowing that will help us get you well." As Lena looked me in the eye with fierce determination, I knew that answer wouldn't work. So I said, "I know all about what it's like to be raised by a strong mother." And I told everyone about my own mother, who -- like Lena's mom -- had overcome medical and social adversity to go on to a distinguished career in the health professions. "So I know a lot about strong mothers," I continued, "and there's no doubt in my mind what I would do if it were my mother. I would choose to stop active treatment and instead work to assure her comfort." Lena looked at me again and nodded. We'd come to an understanding. She and her family might not agree with a recommendation for comfort care, but they knew I was telling the truth as I understood it.
After the meeting, the family elected to continue aggressive life support. I checked in from time to time. Lena told me she knew her mother would die, but still she had to try. Her younger daughter -- I'll call her Olga -- informed me privately that she agreed with my recommendations. Olga and her husband had lost a nine-year-old daughter to cancer, she told me, so she knew about comfort care and how helpful it could be.
A week after the family meeting, I was paged to the ICU step-down unit. "Can you come down now?" the nurse asked. "Your patient is here from the ICU, they weaned her off the vent, the family is here, and they want palliative care." I came down. They still had questions -- could she continue to receive dialysis? would she be allowed to eat? -- and I said that I would like to see the patient again. A glance told me everything I needed to know. She appeared to be sipping the air, not really breathing. Her hands and feet were ice-cold and mottled. She was unresponsive. I looked at the daughters and the husband and told them it would not be long. They cried, they held her hand, they spoke to her in Russian. The nurse and I could see her heart rate slowing on the monitor. And then, just like that, she breathed one more time and was gone.
As it happens, I know the Jewish prayer for the dead. "Would you like to say Kaddish?" I asked. "I know there are supposed to be ten people when this prayer is said, but I think God wouldn't mind." They said yes, please, we want to say that prayer. And so we did, the ancient syllables filling the space and, hopefully, easing her passage. The husband and both daughters hugged me and thanked me, no one more forcefully than Lena. We said our good-byes, and I left them to be with the strong Russian woman they loved.
If it were my mother, I'd want her to die peacefully, surrounded by family telling her they loved her. Just like that.