We Need More

I've stayed away from writing about health care policy -- there are plenty of people out there far better as policy wonks than I could ever be -- but a recent editorial in the Journal of Palliative Medicine calls out for comment. The writer was Dr. Sean Morrison, a leader in the effort to bring hospice and palliative care into the mainstream of American medicine. Dr. Morrison notes that many American medical schools now teach palliative care principles. But the so-called hidden curriculum often works at cross-purposes and devalues the practice of palliative medicine.

You know what the hidden curriculum means. If you've ever heard something like, "Now that you've finished your training, we'll teach you what it's really like to do this job," well, that's the voice of the hidden curriculum. Physicians in training are highly influenced by the words and deeds of their senior instructors and mentors. If those doctors give no more than lip service to the core mission of palliative care -- relieving suffering, helping articulate goals, guiding patients and families through transitions -- then the younger generation will do the same. Monkey see, monkey do.

The palliative care workforce is still too small for the workload. Here are some remarkable numbers that Dr. Morrison cites:

• There is one cardiologist for every 71 persons experiencing a heart attack
• And there is one oncologist for every 141 patients diagnosed with cancer
• But there is only one palliative medicine physician for every 31,000 persons living with a serious, life-threatening illness

Palliative care works. Whether delivered through hospice or not, palliative care programs "reduce symptoms, improve doctor-patient-family communication and satisfaction with care, [and] enhance the efficiency and effectiveness of hospital services," Dr. Morrison writes. To this hospice and palliative medicine specialist, that sounds like an important part of the effort to improve the American health care system's affordability, accessibility, and quality.

To counteract the hidden curriculum, we're going to need a lot more help.

"Does He Have a Cure?"

Dana was too young to be as sick as she was. Diagnosed in her early 40s with a rare form of uterine cancer, her tumor had filled her pelvis and literally was erupting through the skin below her belly button. When I first met her, she was weak, bleeding, and frightened. All of us involved with her care -- the oncologist, the ICU staff, and my palliative care team -- believed that she would only live a couple of weeks at most.

But we hadn't counted on Tom, Dana's hard-charging husband. Tom seemed to believe that he could bend the universe to his will if only he pushed hard enough. In family meetings he did the talking while Dana stayed quiet. Tom advocated continued aggressive care -- more chemo, transfusions to help with anemia and bleeding, radiation treatments -- when it seemed to us that Dana just wanted to stop. It was Tom who recited the list of milestones that Dana had achieved -- getting to attend her daughter's wedding, celebrating a birthday, moving into a new home. She had lived for several months longer than we'd believed possible. None of us were sure that Dana thought achieving the milestones had been worth it. But it was hard to find time to talk with her alone. Tom was a constant presence at the bedside.

Dana lived for much of her last six months in hospitals, spending three months in an inpatient bed at one point without a break. Many days were spent negotiating with Tom, who wanted to blame Dana's weakness on anything -- the drugs, inadequate nursing, the food -- anything but the terrible cancer that was taking his wife's life.

"Am I dying?" is a question a hospice doctor hears a lot. There's no border crossing, no checkpoint, no security screening that demarcates the beginning of the Land of the Dying. One often can only know the answer to the question in retrospect. Certainly from Tom's perspective, his wife was not dying until the very end.

But the end came eventually when Dana was admitted to our palliative care floor for the last time. Tom was still talking about radiation and more chemo, but this time Dana stopped him. She'd had enough, she said, and there would be no more. We focused on comfort -- although Tom still requested, and got, more lab tests and a transfusion just a day before Dana died. And we had endless discussions with Tom about exactly how much pain medicine we could give, because he believed the drugs, and not the cancer, bore responsibility for his wife's decline.

Late one Friday afternoon, I quietly entered Dana's room. She was unresponsive and ashen. I knew from her breathing that her life expectancy could be measured in minutes. Tom was sitting by the bed, stroking Dana's face and holding her hand, his back toward me. Another family member acknowledged my presence with a nod. The atmosphere was so charged, the room so still, that I was afraid to breathe loudly, let alone speak. After perhaps five or ten minutes, the family member said, "The doctor's here, Tom. Do you want to ask him anything?"

A long minute passed, and Tom asked, "Does he have a cure?"

My heart burst open. I had to work to prevent my knees from buckling. And then I looked at Dana. She was gone. I put my stethoscope on her lifeless chest, and Tom -- the man who'd shown no pain, who'd demonstrated nothing but a fierce determination to surmount his wife's cancer -- Tom began to weep.

And I found my inner self rejoicing just a little bit. Not over the death of a brave woman, and not over a husband's pain. But the fact that pain could be expressed, that anguish could be seen -- that seemed cause for quiet celebration. Tom was unlikely to ever be able to heal without taking the first, tentative step of acknowledging his loss and his suffering. I hope he can remain open to the feelings he finally let us see.

And as for me, I know I have to let my heart break over and over again, as I encounter the Toms and the Danas of this world and try to guide them through the Land of the Dying.

Facing Death

If you haven't seen it, you owe it to yourself to watch "Facing Death," a documentary recently shown by the Public Broadcasting Service. Here's the link:

http://www.pbs.org/wgbh/pages/frontline/facing-death/

This documentary highlights some of the trade-offs inherent in high-tech, modern medicine. I thought it was extraordinary that several patients and their families permitted such a personal look at their journeys through serious illness.

As a hospice and palliative medicine physician, I was surprised that symptom relief, comfort care, and hospice weren't dealt with at all. Hospice was mentioned once -- unskillfully, I thought -- by one doctor talking with one family. And I cringed when she said that "doing nothing" was an option. For the record, hospice care isn't doing nothing. It's substituting one goal of care for another. I frequently have hospice patients receiving multiple medications to relieve their pain and other symptoms while our entire team works to assure emotional and spiritual needs are attended to. That's not nothing. That's a whole lot of something -- something that all of us need when we are facing death.

Eight Minutes

"She's 74 with end-stage lung disease," the ICU resident told me over the phone. "BiPAP-dependent, unresponsive, and the family is thinking about withdrawing care." Meaning, Molly wasn't expected ever again to breathe well enough on her own to survive. She was wearing a tight-fitting mask that helped push air in and out of her disease-ravaged lungs; if that were removed, she probably would die within hours. She couldn't be aroused. She had five adult children who now understood that their mom had come to the end of the line.

I gently chided the resident about the phrase "withdrawing care," which I detest -- as someone wiser than me once wrote, we may withdraw certain forms of treatment, but we never withdraw care -- and told her I'd come meet with the family. A son and a daughter were at Molly's bedside. We moved to a small conference room so that I could review the situation. They understood that she would never want to be permanently connected to a breathing machine. One by one the other three kids arrived. I did the same review three more times, spending over two hours with Molly's family. In the end, they agreed on a comfort approach. The BiPAP would come off while their mother received morphine to ease the work of breathing. If she kept breathing on her own, she'd come out of the ICU and would transfer to our acute palliative care unit. To everyone involved, me included, this seemed the most compassionate choice.

And so it went. The morphine was started around six that evening, the BiPAP was removed and an ordinary oxygen mask substituted, and Molly actually continued to breathe without apparent distress all night while maintaining an adequate amount of oxygen in her blood. I came by early the next morning, verified our intentions, and asked the ICU staff to get the transfer going.

Now, in a busy intensive care unit, the top priority is not usually transferring a patient whose care had been "withdrawn" to what some think is the elephant graveyard of the hospital. About four hours passed between my thumbs-up in the ICU and the time Molly arrived on the palliative care unit. I looked at Molly, looked at the orderly pushing the gurney, and said, "Hurry up." She was gray and, I thought, minutes away from death. The orderly hurried. We got her into bed just before the kids arrived.

Our head nurse joined me in Molly's room as the children circled the bed. In turn, each began to say his or her good-bye. When the second child had finished, my experienced eye told me something had happened. The nurse and I exchanged a glance that said: Our patient has just died.

But the good-byes weren't done. It was the turn of the third one, and then the fourth, and then the fifth. Just as the last child finished speaking, I looked at the clock. Eight minutes since Molly had died. I reached for my stethoscope, moved to the bed, and listened for a heartbeat I knew would not be there. And then I said: "That was so extraordinary. I was watching your mom as each of you spoke. Just as you all finished, I could tell that she was taking her last breath. Obviously she waited to say her own good-bye until all of you had said yours." Molly's five children nodded, and cried, and held each other for a long time. The nurse and I expressed our sorrow for their loss and accepted their thanks for making their mother's passing a gentle one.

Then I left the room and falsified the medical record and the death certificate, listing the time of death as eight minutes later than it actually happened.

My profession values truth, and not being truthful on a death certificate is probably a crime. What would you have done?

Overreach

She was 48 years old, she had struggled with her cancer for a long time, and when she was readmitted to the hospital on a Sunday afternoon -- her third admission in as many months -- it was clear she was dying. The on-call oncologist and I met with her large family to talk about our assessment. We reviewed what she'd been through over the course of her illness and more recently -- long admissions for pain and other symptoms, our campaign (ultimately successful) to bring them under control. "But now," I said, "all the decision-making collapses down to one choice: will it be a hard death or an easy death? Will we do lab tests and CT scans and try to restart her heart if it stops beating? Or will we focus on her comfort exclusively, keeping in mind the sad truth that, no matter what we do, she will soon leave us?"

The family's spokesman said they need time -- a few days, he said -- to ponder the implications of what we'd said. I replied that they might not have a few days, that their loved one was so close to death that the choice might be thrust upon them within hours. "Not to decide is to decide," I said. Unless they agreed to a "do not resuscitate" order, if their loved one's heart stopped the code team would come running, tubes at the ready and defibrillators fired up. "Is that what she would really want?" I asked. The family would not budge. So we moved into disease-modification mode. We did tests and normalized abnormal values. And I kept talking with the family, since the patient herself really couldn't communicate at that point. As they raised different questions -- did the improvement in kidney function tests mean that her kidneys were permanently better? what about nutrition? -- I kept returning to what I thought was the central question: what kind of death would she have?

Thinking back, I'm sure I was trying to protect her from her family. I could see what was going to happen, but they could not. So I pushed harder than I should have. I didn't want her to have the kind of high-tech death that the family's non-decision was leading to. And they pushed back, ultimately moving their loved one to an acute medical floor and making it clear that I was "too negative" and was unwelcome at the bedside.

So her last three weeks of life included another CT scan (predictably showing further cancer growth), two surgeries to drain urine into bags on the outside (since the cancer blocked the tubes connecting the kidneys and the bladder), multiple transfusions, and many blood tests. I watched from a distance, feeling the pit in my stomach growing each day. Finally, she had a seizure. The code team was called at six in the morning to intubate her for "impending respiratory failure." The anesthesiologist literally had the tube in his hand when the patient's daughter, just barely an adult but still the designated power of attorney, screamed that they had to leave her mother alone, that she would not have wanted this, that they had to make her DNR.

So they did, and eighteen hours later she was dead.

I grieved for her then, and I grieve for her still. I lament that I could not save her from the hard death she experienced. And I feel guilty that it was partly my fault. What if I'd taken another approach with the family? What could I have said, or not said, that might have made a difference? I'm so often told that I've said exactly the right thing to help patients and families make tough choices. Why did I overreach here?

The honest answer is that I loved her.

No, no, not that kind of love. Not even a Jimmy Carter-esque "lusting in the heart" kind of love. I loved her for her courage, for her unfailing sense of humor, for her grace under pressure, for her passion about what mattered to her. (If you were to Google her name, you'd find that she was a human rights activist on two continents.) I loved her for her willingness to endure just to spend more time with her extended family. I loved her because -- as is true for most patients I've come to love and admire over the years -- she showed me what kind of person I ought to be.

We try to protect the ones we love. Sometimes we can't. In this case I didn't, as the psychiatrists might say, manage my transference very well. But tomorrow morning I'll still work to protect my patients from suffering and unnecessary pain at the end of their lives -- hopefully without overreaching.

Memorial

As a hospice doctor, I go to a lot of funerals. My patients' families are always amazed and grateful when I attend, but that's not why I go. Part of it is about closure and paying respects, of course, but I derive another purpose from the trip to the church or synagogue or funeral home. Often it's only at the funeral that I get some sense of what my patients were like before I met them. When they are eulogized, or when I see a wall of photos under a heading like "A Celebration of the Life of..." I'm often amazed myself. I get a sense of my patients before they were my patients, when they were strong and vibrant spouses, parents, and members of the community.

That's what I expected would happen when I went to a memorial service recently. Rob had been a young man, only in his mid-forties when cancer took him. He'd had ties to the world of show business, so it didn't surprise me that his memorial included elements of stagecraft, expert video editing, and music. And I wasn't surprised that a lot of people were there -- maybe two or three hundred, filling a small auditorium in the artsy part of town.

What did surprise me was how much I cried.

I've shed a tear at other funerals, and even at the bedside (although there I am always careful, lest my needs take center stage over those of my patients and their loved ones). But this time was different. I didn't censor, I just let things happen and tried to make sense of my feelings as I watched the outpouring on the auditorium stage of love, genuine love, for Rob and what he had done for those he'd been close to.

And then I understood. I wasn't crying for him. I was crying for me.

I cried because I couldn't imagine a memorial service for me looking anything like the one for Rob. I cried because I couldn't imagine that twenty people, let alone two hundred, would give up an evening to say nice things about me. I cried because I couldn't imagine that my life, already a lot longer than Rob's, would ever have that kind of meaning and impact. I understood then that my patient's short life was telling me to live the rest of my own life better -- to be warmer, and more open-hearted, and more loving.

As a hospice doctor, I go to a lot of funerals. I also get the chance to examine my own life daily as I navigate through the suffering that my patients and their loved ones endure.

The Opposite of Love

Under the heading of "I wish I'd written that," I refer you to a wonderful posting on another blog that I follow:

http://www.geripal.org/2010/05/opposite-of-love.html

Time to Grieve

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.

Revoke -- An Update

Last month I wrote about Adele and how her family's anguish played out in their decisions to enroll in hospice and then revoke the benefit a day later. I speculated that Adele would die an uncomfortable death in a nursing home, unless the home panicked (as they are prone to do) and returned her to the hospital.

I've had some follow-up about Adele. She left the hospital and moved to a nursing home. About ten days later, at the family's insistence, she was brought to the emergency department. They felt she wasn't doing well. The ED did its job, finding no changes of any substance, and she went back to the nursing home. A week later I discovered that she was once again a hospice patient  -- enrolled with another program, not with mine -- and on their inpatient hospice unit. She died there several days after admission.

So I advocated for hospice, the family accepted and then rejected my advice, and finally accepted it again but went with a different hospice program? What's the take-home message here? Should I be gloating that they finally saw things my way? Angry that they rejected my program in favor of another? Depressed because I wasn't a good enough palliative medicine specialist to get them to stick with their first decision?

I vote for "none of the above." Instead, I think Adele and her family teach us two important lessons.

The first is that bearers of bad news do so at that their peril. "Don't shoot the messenger" applies equally well to warfare and the breaking of bad news -- not that there aren't other parallels, by the way. I think one reason Adele's family chose another hospice the second time around was because it was so hard for them to get there. 

The second is that, faced with the devasting realization that nobody actually does live forever, each patient-family unit carves its own trajectory and proceeds at its own pace. The process can't be hurried. Sometimes I think that our job is to shield families, to protect their emotional space while they wrestle with the tough decisions they'd rather not have to make. Creating a safe, non-judgmental context for patients and families is part of the work I do every day.

Revoke

We all know in our heads that no one lives forever, but it's a different matter altogether when our loved one is dying in front of our eyes. For adult children facing hard choices about their desperately ill parents, the dynamic is often filled with grief and pain.

Recently I was asked to see Adele, a woman in her eighties who'd sustained a large stroke involving the left side of her brain. It was clear to all that her massive brain damage meant she'd never function independently again. And then there was the cancer. An abnormal admission chest x-ray prompted a CT scan that showed a nasty-looking nodule in her right lung. Other tests convinced Adele's primary medical team that the cancer had spread from another source. The consulting oncologist recommended comfort measures instead of aggressive diagnostic efforts. I was asked to consult. Adele was unresponsive and not arousable, holding her eyes at half-mast, and breathing through her mouth.

Adele's husband was distraught to the point of paralysis. "My daughter will be here soon, " he kept saying. When she arrived, it was obvious there was no love lost between parent and child; it seemed that every third or fourth sentence she said was a variation on the theme of, "Dad, be quiet." With some difficulty we talked about hospice as a means to help Adele die comfortably and with dignity. Adele's daughter accepted my advice to start down the comfort path. She and her father signed the papers, her mother was moved to the hospice part of the hospital, and staff worked to align her treatment orders with the exclusive goal of reducing pain and suffering.

The next day, all hell broke loose. Both father and daughter announced loudly that Adele wasn't getting good care and that they had moved to hospice way too soon. They wanted out, and they wanted out now.

It's actually a simple matter to quit hospice. You sign a couple of forms, and -- abracadabra! -- you are right back in the conventional health care system. Adele moved back to a regular medical floor. For the next ten days, various doctors once again noted her dismal prognosis and the near-zero possibility of improvement. The stomach specialist, who gets paid to put in feeding tubes, wrote an eloquent note about why it would be immoral to put one in Adele. All to no avail. The family insisted that Adele would soon recover and be like her old self. At the family's request, the social worker found a nursing home that would take her, and off she went. 

Now, I haven't visited Adele's nursing home. But I'd wager that its care doesn't compare to that provided every day on our hospice unit by nurses who want to be there and who specialize in end-of-life care. So the decision to revoke couldn't have been based on care delivered, at least not when assessed objectively. But why would this family make a decision so obviously not grounded in objective reality? Why give up a good thing like hospice? Why, as nurses and physicians wondered aloud, did they want to torture her?

The author Francine Russo recently wrote, “The real challenge in making decisions about life-extending treatment is how much we can focus on what our dying parent needs rather than our own anguish. This is the ultimate test of emotional separation.” I believe Adele's family had trouble with emotional separation. I think their anguish at the thought of losing her blinded them to a loving and compassionate assessment of what she needed when she needed them to put her needs first.

Adele will die at the nursing home, unless she develops an abnormal vital sign that panics the facility into sending her to the emergency room. In that case, she'll die in the hospital while facing the full brunt of modern, disease-oriented medicine. Either way, it will be an entirely preventable tragedy. We need to put our loved ones first.

Medicate, Medicate

Families of hospice patients often complain that their loved one is "over-medicated." Dad isn't arousable and isn't talking, so it must be the morphine. If only we would turn down the drip, Dad would wake up and interact, or so the reasoning goes. A variation of this theme is the request that we reduce the pain medicine while family is visiting so that they can chat with Dad, then turn it back up later once everyone's left so that he can sleep. One of our many jobs is to gently explain that it's the disease, not the drugs, that is responsible for the patient's decline. We can't manipulate our patients' level of consciousness the way families often think we can.

 

A central tenet of hospice is that we don't hasten our patients' death, nor do we stand in the way of death. So we're sensitive to the charge that we're giving too much medicine when what we are trying to do is assure our patients' comfort. We give drugs the way Goldilocks might -- not too much, not too little, but just right.

Not long ago, I ran into the opposite problem. Anne was in the last phases of her colon cancer, admitted to our inpatient unit and, by the assessment of every staff member, comfortable and pain-free. "Not so," said her two adult daughters, "we want her sedated even more. Our mom is a stoic. She wouldn't report pain to you. But we know she's in pain, and we want her to have more morphine." Anne was intermittently conscious, and she had blinked when the daughters asked her if she was in pain. That was their evidence. But her face and body were relaxed, and her breathing was easy -- all signs that tell hospice workers their patients are pain-free. The staff felt they were being railroaded into giving more medication than they felt was justified. A nursing supervisor recorded a conversation at four o'clock in the morning with one daughter. "Are you telling me you want euthanasia for your mother?" she asked. "Yes" was the reply.

I spent a couple of hours with the daughters over the last two or three days of their mother's life, talking in great detail about how we assessed patients and why we thought she was comfortable. I explained how we balance giving enough medication to relieve suffering while trying to avoid any hastening or acceleration of the dying process. The daughters didn't buy it. Right up to the end, when Anne was deeply unconscious and skipping breaths for 30 seconds or more, they clamored for more drugs. Our staff was convinced that Anne died peacefully, but there was no peace for those she left behind.

What motivates families to make a request like this? There are cynical explanations -- a son needs to get back to work, or there's a lot of money to be inherited. It's hard to believe that getting a will into probate faster would motivate a child to ask for euthanasia for a parent, but I suppose it's happened now and then. Or there may be an ambivalent relationship between players in the end-of-life drama. Perhaps there are unresolved issues stemming from childhood. Now that the child can, in effect, exercise parental power over his parent, it may be tempting to turn the tables once and for all. That, too, has probably happened from time to time.

But I believe the reason lies most often with the intense pain that people feel when their loved ones are dying before their eyes. Pain...and impotence, the inability to change the outcome, to protect a loved one from the finality of death. If I have no power to prevent my wife from dying, then I'll exercise my power to prevent her from feeling any pain at all. Both hospice workers and families share the goal of relieving suffering. But because we work in the fishbowl that is America's ambivalence about dying -- think of the "Obama death panel" insanity -- hospice people also must be sensitive to charges that "all you do is give them morphine and kill them." That need to balance is irrelevant to families grieving the loss of a loved one in advance of the loss itself. And therein, I think, lies the seed of the conflict we had with Anne's daughters. I know of no easy solution to the "medicate, medicate" dilemma other than to educate, educate.

Emergency

She was 92, desperately ill, and screaming at the top of her lungs. I was rounding in the hospital when I got the call from the residents in ICU -- could I come right away? Of course I could. It's hard enough dealing with critical problems when you've got some physician miles under your belt. But it's truly terrifying for a young doctor, just months out of medical school, to face a problem that doesn't easily reduce itself to lab tests and x-rays. I've long felt a responsibility to not leave physicians in training alone to stumble in the darkness.

She lived in a nursing home, which shipped her to the emergency department because she was "altered." In other words, she was acting crazy. The ED did its job. The staff quickly determined that she probably had a serious infection, that her kidneys had stopped working, that her lungs and heart were perilously close to failure, that her blood would no longer clot. She was bleeding from her rectum and possibly into her head. Her odds were slim to none. Family members quickly gathered before she was sent upstairs to ICU, yelling and thrashing on the gurney. The nurses responded by tying her wrists to the bedrails.

Blessedly, the family's first question was, "Do you have a palliative medicine doctor available?"

The residents and I quickly confirmed the ED's findings. Even before I briefed the family, I talked the residents through some basic moves -- small amounts of a powerful pain medicine called fentanyl, safe when the kidneys shut down, to treat the obvious pain; an antipsychotic drug, haloperidol, to calm her and hopefully allow us to remove the restraints; and a drug to reduce the gurgling noise she made with every breath, chosen carefully since some medications of that type can worsen delirious behavior. We decided to keep the family in a separate room until their loved one was less uncomfortable. Why should their last visual memories be of a person so obviously not at peace? But it took too much time for things to happen. No one was moving at an acceptable speed. Dying patients who are not getting life-sustaining treatments sometimes fall lower on the ICU priority list. I finally spoke to the nurse in charge: "This is an authentic palliative care emergency, just as surely as a cardiac arrest is an emergency. We need these meds to be given, and we need that to happen now." My voice was under control and I stayed calm, but there was no doubt about what I expected would happen next. Drugs appeared and were given quickly. After a few minutes we could already see that our patient was calmer, still awake but not nearly so agitated.

Ten family members and I talked in a conference room smaller than most walk-in closets. I reviewed the test results and the prognosis. Unlike so many families I deal with, this family closed ranks quickly around a unanimous opinion -- treat for comfort, and allow a natural death. I returned to the unit, worked through some dosage adjustments with the residents, and asked the nurses to untie the dying woman. About 45 minutes after she arrived in the ICU, our patient was ready to receive visitors. The family crowded around the bed, saying their good-byes. A little later, our 92-year-old mother, wife, and grandmother closed her eyes, and three hours after she came through the doors of the ICU she was gone.

If we have nothing else to offer, it seems to me we can at least offer the possibility of a smooth transition from this life to whatever may or may not follow. In medicine, an emergency means a situation that just can't wait. A delirious elder at the end of her life, obviously suffering with a life expectancy of minutes to hours -- if that isn't an emergency, what is?