A rare case when needs of the dying should be secondary

I pulled the stifling surgical mask off my face as I left my last patient’s room. I had just finished suturing a complicated facial laceration and was bone-tired from the evening. Glancing at the clock, I saw that mercifully, my shift was over.

Collapsing into my chair to finish up my charting, I was slightly annoyed when my nurse held a clip-board in front of my face, “Here is your next patient.”

“No, really, I’m done …” I started to explain to her until I saw what was written on the papers held by the clip-board… “Patient is ready to quit dialysis. Son doesn’t want him to.”

“Oh,” I said slipping down deeply into the chair, “I guess this is my patient.”

So, taking a deep breath to shake off some of my fatigue, I headed toward this patient’s room. Glancing at the chart before I opened the door, I noted that the patient’s name was Mr. Bryan.

“Knock, knock … Mr. Bryan?” I called out while pushing open the door with my shoulder.

“That’s me,” a tired figure said from the hospital bed.

Mr. Bryan was a large-framed man of about 70. His physical largeness accentuated his posture- head hung low almost as in defeat; shoulders drooping … tired. His weariness was so profound that my own fatigue seemed to slip away in insignificance.

I stood up straighter and offered my hand both to Mr. Bryan “senior” and Mr. Bryan “junior” who sat beside him, “Doctor Murphy, so nice to meet both of you.”

I pulled up a stool next to the elder Mr. Bryan’s bed. “My nurse tells me that, as a family, you are struggling to make decisions about whether to continue dialysis or not,” I stated rather matter-of-factly, not needing to act as if I didn’t know the crux of the issue at hand.

My patient, with his head still hanging low, nevertheless raised his eyebrows with, I think, surprise that I was willing to start at the heart of the issue.

Taking my lead, Mr. Bryan unmasked himself and began at the very core of his own deeply personal saga. What ensued was a conversation unlike any that I have ever had with a patient before.

“Doctor, I know you are busy, but I have something very complicated to explain to you. You see, I am a bit of a philosopher, and have done a lot of reading. I think this whole life thing is some sort of mental construct … and, when you die, you become free of all this. Free and unattached from whatever your life has been, unattached from any of the tragedy of life, unattached from the entanglements of relationships gone bad or even good.”

I leaned in toward Mr. Bryan to give him my full attention.

He continued, “I just don’t think any of this matters after you die … I have come to the point where the physical tax of continuing to live artificially (via 3 times weekly dialysis) has exceeded my desire to stay in this life, and to stay in all of these attachments. I’m ready to be done, to be free.”

After a pause, Mr. Bryan said, “My son here will not like hearing me say these things.” He looked down at his own white-knuckled grip on the blanket rather than at his son who sat along the opposite bedside.

Mr. Bryan “junior” then explained to me that his was actually “OK” with his father being “done” but that he had asked his father to please continue dialysis until his only sibling, a younger brother could drive down from New England to “say goodbye” and to have closure. “Surely, Doctor, this cannot be too much to ask,” he pleaded his case to me.

Mr. Bryan “senior” responded and stated carefully, “But, these relationships won’t even matter to me after I’m dead. You and your brother won’t have to worry about me after I have left this world.”

Finally, I interrupted and said, “But, Sir, you must be careful how you leave.”

Mr. Bryan “senior” turned to look me in the eyes for the first time, “What do you mean, doctor?” and Mr. Bryan “junior” looked toward me with faint hope and surprise.

I had sat very quietly listening without judgment during the preceding conversation. I could understand my patient’s perspective, as well as his son’s. Both wanted closure, just different types.

However, it suddenly became clear to me that the son’s desires should trump my patient’s desires. I recognized this as one of the few instances in which I thought the needs of the one dying should be secondary to the needs of others.

I explained to my patient, “Mr. Bryan, in your view, you are ‘checking out’ of this “construct;” which is fine, you are ready to move on, you have lived a full life … I get it. But, I urge you to think of those of us who you will be leaving behind in this “construct.” You will be gone, but your sons will have to go on living. They will still be here entangled together in this thing called life. The manner of your leaving creates a pattern for those left behind, like the cloud trails of a jet plane. If you actually choose to ‘leave’ before your sons have the opportunity to create closure and peace with you, then you are choosing to leave behind a legacy of sorrow and maybe even suffering. In contrast, if you ‘stay’ a little bit longer, long enough to heal old wounds, and finalize peace; you will leave trails of gratitude. You may be leaving this world, but how you go leaves a lasting impression- an impression which could affect not only your sons, but possibly an entire generation of your family, and others.”

Then, we all sat quietly looking at each other, and around the room in thought.

I guess my ideas had some merit in my patient’s eyes. Mr. Bryan “senior” chose to continue dialysis until his youngest son arrived. I advised expressions of forgiveness and to share the words: “Thank you, I love you, and goodbye.” I think they took my advice.

In the end, Mr. Bryan and his son crystalized this lesson for us: If we are fortunate enough to die consciously, then we should take full advantage of opportunities to create peace for all parties. Our last words and intentions matter so much to those left behind. We should be careful how we leave.

Monica Williams-Murphy is an emergency physician and author of It’s OK to Die.

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