Giving the patient and family precious minutes to say goodbye

An excerpt from Doctor Confidential: Secrets Behind the Veil.

by Richard Sheff, MD

Dorothy suffered a second heart attack, leaving more of her heart muscle damaged and causing her to slip into congestive heart failure. There was not much we could do to reverse the many blockages in her arteries. Yet she was cheerful, as were her four children.

One morning Mary came to find me. “Dorothy says she isn’t feeling well.”

“What’s going on, Dorothy?” I asked lightly as I walked into her room. At a glance I could tell she was in trouble. Pale and sweaty, she could barely catch her breath. “Dorothy, are you having chest pain?”

“Dr. Sheff, I didn’t want it to happen again…”

“Get a STAT EKG. Bump her oxygen to 100 percent rebreather mask. Give her nitro sublingually, and get Dr. Patel on the phone immediately.”

“I can’t breathe, Dr. Sheff…”

“Page anesthesia for a STAT intubation…”

…Her panicked eyes darted from me to the anesthesiologist as he coaxed the endotrachial tube past her vocal cords. She looked at me imploringly, but could say nothing because of the tube.

“Blood pressure’s down to 70,” Mary called out.

“Hang dopamine at 8 mics and titrate to a BP of 90 systolic.”

Several hours later Dr. Patel, her cardiologist, came in. “She’s infracted one more time. We’re barely able to get her BP over 80 with dopamine,” I informed him.

“Looks like her heart’s shot. Switch her to norepinephrine…It should keep her alive long enough to see if her heart will recover from this latest insult.”

…Dorothy’s eyes implored me, while her mouth worked around the tube suddenly filling her throat. She strained to say something I could not understand. Frustrated, she finally gave up. When her daughters arrived, she again tried to speak. In desperation we gave her a pad…but the very act of raising her hand to write exhausted her. Finally we made out the scrawled words, “I love you all,” the last words she was able to communicate.

For four days Dorothy hovered in this state. The norepinephrine sustained her blood pressure just enough to keep her alive, but at a cost. The blood vessels to her extremities clamped down, turning her hands and feet black. The tips of her fingers and toes began sloughing off, leaving desiccated stumps no longer able to feel loving touch. Mentally she remained alert and increasingly frustrated at not being able to communicate with her family.

On the fifth day, her blood pressure started to slip. Unlike most physicians, Dr. Patel knew when to stop. “No reason to keep pushing,” he concluded. “Wean the pressors and let her go.” He turned to leave the unit.

Though this seemed the most humane thing to do, something didn’t feel right. We would stop pushing to keep her alive, stop goading her frail heart to keep going when it so clearly wanted to finally rest. We would sedate her, and she would die peacefully. Wasn’t this the kind of compassionate death in which I was coming to believe? What was nagging at me? In response, the question I’d formulated more than a year ago early in my internship came back.  At this moment, what is the most loving thing to do? I knew what was wrong.

“Dr. Patel,” I chased after him, “she’s been trying for days to communicate with her family. Since she’s going to die anyway, could we extubate her so she can talk to her family before she dies?” This was a bold suggestion from a resident still in training to an attending cardiologist, but I knew it was what she would want, what she needed to die well.

“Do what you like,” he said dismissively.

With her children’s quick agreement, this became the plan. One by one her daughters joined together at her bedside…Finally her son, Bill, arrived…I leaned over her. “Dorothy,” I began slowly, “you know you’ve had another heart attack. Your heart is now too weak to keep going.” Her eyes widened with understanding. She tried desperately to say something around the tube. “Dorothy, I know how hard you’ve been trying to communicate with your children.” She nodded. “They want to hear what you have to say.  They also want a chance to say goodbye. If it’s alright with you, I’ll remove this tube so you can say whatever you want to each of your children.” Again she nodded, a look of deep gratitude coming over her face. We both knew she was dying. With astounding speed of insight, she accepted this shattering truth, and in an act of exceptional courage wanted nothing more than to share a few loving words with her children in whatever time she had. This was in my power to grant her, a power thrust into my hands as a physician…Thankful to be able to use this power to help her as I sensed she so desperately wanted, I removed the tube and stepped back.

First Marie approached and knelt next to her mother’s head. With soft eyes and quiet words, Dorothy said something only she could hear. Marie let out a moan and buried her head on her mother’s shoulder, pouring out what needed to be said for mother and daughter to part in peace. Each sister took her turn. Then Bill knelt next to her. With her last lucid moments, mother and son exchanged final words. Dorothy’s eyes closed as she seemed to drift off to sleep. All eyes turned to the monitor over her bed which captured each slowing heartbeat. Her chest rose and fell. Then, in great peace, her heart simply stopped.

I hugged each member of the family and left them to their grief. I knew with certainty that I had just done something important. I did not know at the time that allowing Dorothy and her family these precious minutes to say what needed to be said and then to say goodbye would remain one of the finest things I would ever do in my career as a physician.

Richard Scheff is a family physician and author of Doctor Confidential:  Secrets Behind the Veil.

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