Thursday, February 16, 2012

Way to Go

Bertie was 91, and in an earlier, less politically correct era she would have been called spry. She'd been enjoying her life, which was happily free of major, chronic illness. She was surrounded by children, grand-children, and great-grandchildren, along with a network of friends and neighbors in her rural town. And she'd been married for over 60 years, although lately she'd been visiting her husband at a rehab center where he was recovering from a hip fracture. Bertie had barely been sick a day in her life.

About ten days before she died, Bertie had developed a stomach ache -- nothing serious, and nothing that had gotten in her way. Eight days before she died, though, the pain got much worse -- so much so that her family rushed her to the hospital at two o'clock in the morning. She was pale, weak, and in pain with a dangerously low blood pressure. Yes, the family said, we want everything done.

"Everything" meant a rapid-fire evaluation using the best that modern medicine has to offer. And that evaluation quickly revealed the problem. Bertie had a mass in her liver that was bleeding into her belly. It appeared to be a metastasis from the breast cancer that was visible on her CT scan and which also had spread to lymph glands in both armpits. Happily, the bleeding appeared to stop on its own, and after some fluids and transfusions Bertie appeared stable. Four hours after arriving in the ER, she was sent to intensive care.

At 9:30 that morning I walked into ICU planning to make rounds with the team. The attending asked me to see Bertie instead. Her life-prolonging options were bleak. Surgery was basically out of the question. The ICU team had thought about embolization -- threading a thin catheter into the bleeding area and shooting pellets into the vessels to cut off the blood supply -- but that would leave dead tissue behind to form a focus of infection that also would take her life. When the ICU folks can't think of anything else, they tend to think of me.

Bertie was being attended to by two of her children and several grand-kids. I sat down alongside her bed, introduced myself, and asked, "So what's your understanding of what's going on with you right now?" She looked me in the eye and said, "I'm going to die, and probably soon." "How are you doing with that?" I asked. "Oh, just fine," she replied, "I'm old, I've had a good life, and nobody lives forever."

I looked around and saw her children nodding in agreement, although they were tearful. "Well," I said, "let me explain where we might go from here." It's been my experience that patients and families often feel they have just two choices -- sticking with conventional, cure-oriented medicine (no matter how remote the possibility of cure), or doing nothing. "I'm here to tell you," I said to Bertie and her children, "that there's a third choice -- assuring your comfort for however much time you have left."

Bertie gave me a big smile and told me I was the best doctor she had ever met. Her smile wasn't forced; it was as if her whole body was smiling, and radiant, and at peace. Fourteen hours after arriving in the ER, Bertie was transferred to the inpatient hospice unit. She spent a couple of comfortable days there and then decided that she wanted to go home. The hospice team continued to support her and her family at home, where she died peacefully a week after our meeting in the ICU.

Now, I'm not at all sure if I was the best doctor Bertie had ever met. But I am sure that Bertie had a wonderful life and that she approached its end with the courage and grace that we all hope to achieve. She was clear-eyed and clear-headed every step of the way. Like everyone else she came into this world crying and screaming. But unlike so many, she showed us how to have a comfortable and gentle passing from this life to whatever may lie beyond.

Way to go, Bertie -- way to go.

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