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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  • http://WWW.MIRECHO.COM SuJ

    Wow, thank you for this. Working with a population that has to deal with death constantly, this is a great reminder of the humanity behind care and medicine.

  • Winslow Murdoch

    This is the type of experience that keeps me in primary care family practice, and involved in varying degrees with inpatient medicine.
    As a private practitioner of advancing middle age, I hope younger docs who are more than likely to work for hospital or large corporate run practices don’t lose this type of connection.

    As a long time caregiver who most likely knows the patient and family intimately, the meaning of this interaction is infinitely deeper and more gratifying.

    Two years ago, a lovely elderly patient of mine, also whose family I had cared for for two decades, infarcted her entire small bowel after her tenth small bowel obstruction and multiple surgeries. She was in severe pain and progressively
    acidotic. While on a dilaudid drip waiting for the end, she said goodbye to her family one by one in the ICU. After the family was finished, she asked me to stay a while as she and I left each other laughing as she whispered into my ear….
    Every time she had come in or I had seen her in the office or the hospital, she would gush at how good a doctor I was in as public a way as she could.
    I told her that this made me very uncomfortable and embarrassed, and that as usual, I was just doing my job as a conscientious if not more than slightly obsessive primary care doctor.
    I repeatedly told her that her accolades, not to mention in front of other health care workers was embarrassing.
    Our little dance was resolved in her telling me that instead of
    showering me with compliments, she would shower me with
    insults. “I hate you doctor Murdoch” Loud and clear as she would hug me and laugh.
    In her dying minute, after saying goodbye to her large family, she asked for me to come to her ICU bed, hugged me and whispered into my ear how much she hated me, and started giggling. She then asked me to ask the palliative team to turn
    up the Morphine drip as massively infarcted intestines are reportedly one of the most painful ways to die.
    I still care for several of her family members who remember the care and caring that lead to that fateful day.

    Winslow

  • http://www.idealmedicalcare.org/blog/ Pamela Wible MD

    Richard ~

    ” I knew with certainty that I had just done something important. ” Yes, you allowed yourself to be a human being which is what patients need from doctors.

    Unfortunately your dismissive attending was unable to participate with you in this scene. Would have been therapeutic for him, I believe.

    Reminds me of a similar event in my young days as a doc:

    “On Valentine’s Day at my first job I admitted a colleague’s patient, an elderly man dying of heart disease. His wife, unable to bear the pain of watching him die, left his side. I could have left too, but it didn’t seem right to let this guy die alone on this romantic day so I sat with him, held his hand, and cried. A cardiologist, startled by my emotion, said, “You must be a new doctor,” then disappeared down the hall. Maybe old doctors don’t cry, but I don’t want to close my heart to the world. Why is it unprofessional to love patients anyway? Maybe love isn’t valued in a traditionally male-dominated profession. After all, love is not easily measured or reimbursed. Love is hard to control.”
    (excerpt Goddess Shift: Women Leading for a Change, Pamela Wible)

    In the last moments love is all that matters.

    Thank you for doing what you did.

    ~ Pamela

    Pamela Wible MD

  • Molly Ciliberti, RN

    Thank you for your act of kindness and compassion. You did more for her by removing that tube than all of the other things done to her over her last days alive. We had an elderly man dying in the ICU and we were short staffed and couldn’t stay with him in his final hours. He asked not to be alone and the “doctor of the day” Dr. Tom I. sat with him and held his hand while he died (the overall house was quiet that night). I have never forgotten that act of kindness and humanity and have admired Dr. Tom I. ever since. We raise lots of animals at our house and when one of them is dying in a pasture (usually of old age) the other animals eve those of a different species surround the dying one and keep watch through the night and until death. Social animals do not want to die alone; they reach out to each other for solace.

  • http://louisianaqio.eqhs.org Lisa Stansbury

    How beauitful! Thank you for posting this.

  • Harold Boll

    Very moving; nice to know that there are docs out there with a heart.

  • gzuckier

    This is exactly what I, and probably everyone on earth, wants in a doctor. Unfortunately, this is also similar to what some folks refer to as death panels.

  • Chris Mason

    wow. glad i read this post.

  • C. Henry

    Wonderful article. Having just lost my father in November to a heart attack. I would have been blessed to have been able to say goodbye. Thank you for your compassion.