The sage doctor who stood at the bedside as I held my dying grandmother said, “We seem to die one organ at a time.” I, however, have come to believe that we are too focused on the failing of the organs to rightly perceive the dying of the person.
Death comes in many different ways, in many different packages. Sometimes it arrives wrapped thoughtlessly in advanced dementia, other times the package is stained red with the blood of exsanguination. Usually, these packages are wrapped in a fashion that, for the careful observer, indicates the content. On occasion, the package arrives and is not recognized even by the most astute among us.
How can we learn to recognize death in the face of the myriad of medical disorders that may deliver it? How can we see the forest despite the distraction of the trees?
Let me tell you the story of Bonnie Mitchum, a patient of mine whose death arrived packaged only in a few broken bones.
“Dr. Murphy… Mrs. Mitchum, the 88 year-old mother of the trauma patient in bed 46 is being transferred in from Carltonville Hospital. She has 3 broken ribs, a fractured hand, and a broken foot. She will be here in 5 minutes, and I’m going to put her in bed 45 to be beside her daughter and so that the family can all be close together.”
“Good idea”, I responded to Kylie, the ER nurse supervisor for the evening.
“She doesn’t sound too bad off,” I thought silently. I was already mentally comparing Mrs. Mitchum to her daughter who was in bed 46– who did seem ‘bad off.’
They were both victims of a motor vehicle crash. The daughter had two open fractures in her right leg and had arrived with jagged bones sticking out of her thigh and calf; with a cold blue pulseless foot. She was about to go up the operating room for Emergency surgery when her mother arrived. I had wanted to give the daughter an update on her mother before she went up to the OR, so I went immediately in to see Mrs. Mitchum as soon as she was placed in her room.
I pulled back the trauma room curtain and stepped inside, pausing at the entryway. I was immediately puzzled, a look quickly picked up on by the nurse.
“What did the doctor at Carltonville give her for pain?” I asked, because Mrs. Mitchum was sitting up in bed, looking very peaceful with a faint drowsy smile on her countenance. She appeared to be completely comfortable, in stark contrast to every other trauma patient who I had ever cared for in ER with broken bones or other injuries who was actually conscious on arrival.
“Nothing.” He responded with eyebrows raised high, likewise in surprise.
“Nothing?” I asked to be sure, while rifling through her transfer paper for proof this was the case.
“Nothing.” He responded again.
He was right. According to the hospital who saw her first, the doctor wrote that the patient states she had very little pain and “didn’t want any medication.” Still puzzled as to how she could be so comfortable despite her injuries, I put down the papers and moved toward her bedside for an official evaluation.
As I walked toward her bed, her facial features came into sharper focus. Immediately, I noticed two things which I found to be slightly disturbing:
1- Her eyes were gazing upward in what I sometimes call “the heavenly stare” (I consider it a near death sign when people appear to be looking beyond the room and not focusing on objects or people in the natural environment.)
2- Her lips were “poofing”—a very non-medical term for a gentle billowing of the lips when exhaling. This usually indicates to me: very relaxed facial muscles, usually seen in sleep states or impending respiratory failure. Given her rib fractures, respiratory failure was my first thought. I also knew that rib fractures in the very old could be the ‘kiss of death’.
Suddenly, I knew instinctively that Mrs. Mitchum was dying. In her face, I could see both the forest and the trees, the package and the message it contained. Mrs. Mitchum had, by most medical understanding, just a few moderate injuries, a few broken bones, but somehow I knew this would prove to be ‘too much’ for her.
I felt almost guilty having come to this conclusion without actually talking with her or closely examining her, so I proceeded with my usual.
“Mrs. Mitchum?” I used my most gentle voice.
To my surprise, she turned her gaze to my face and focused on my eyes. She was very lucid.
Mrs. Mitchum , are you in any pain?
“No, not really.” She replied very clearly.
I furrowed my brow, “These broken bones aren’t hurting you?” I touched her wrapped and broken left hand. “Do you want something for pain?”
“No, not right now,” she responded.
How could this be so? I again questioned whether she was really clear minded. “Mrs Mitchum, I’m going to ask you some dumb questions now, just bear with me and tell me the answers, ok?”
“Can you tell me your full name?” I asked.
“Bonnie Lee Mitchum,” she responded correctly.
“Do you know what year it is?”
“2010,” she answered correctly.
“Do you know where you are?”
She named our hospital correctly.
“Hmm.” I wondered aloud and turned to look at Adam, her nurse. Simultaneously, we walked toward each other for an informal conference just out of ear-shot of our patient.
“Adam, I think this little lady is going to die.”
“I’m glad you said that doc, I was getting the same impression,” Adam responded, appearing relieved that I was picking up on the same vibe that he was.
“Seems like she is thinking clearly. She’s got decision-making capacity, so we’d better ask her about ‘code status’ while we still can. I don’t want to end up doing chest compressions on her. Three broken ribs are enough for an 88 year old lady.”
Adam was nodding in agreement.
“Come on, you can be the witness.” I motioned to Adam and we both moved back to Mrs. Mitchum’s bedside.
I picked up Mrs. Mitchum’s hand and leaned over the rail of her bed close in to her face. “Mrs. Mitchum, I have some very important questions to ask you, OK?”
She opened her eyes and gave me her full attention.
“Rib fractures can sometimes make it hard to breathe. Some people who get broken ribs may have to be put on a breathing machine, if they couldn’t breathe well or if they stop breathing. We will keep your pain controlled no matter what, but if you couldn’t breathe well on your own or if you stopped breathing, would you want us to put a breathing tube in your throat and put you on a breathing machine to support your lungs?”
“No,” she shook her head.
“I understand your wishes, Mrs Mitchum. And I have two more questions like this.”
“If your heart stops beating, do you want us to do chest compressions on you? To do CPR?”
Very peacefully she responded again, “No.” There was no hint of shock or even concern that I was asking her questions of such gravity. She continued to have the same tranquil expression on her face that she had at her arrival.
The final question: “Mrs. Mitchum, if your heart stops or is beating in a way that would cause you to die, would you want us to give you electrical shocks to try to fix your heart beat or to bring you back to life?”
“No. I’m 88,” she said, “I won’t need all of that.”
Adam started on the Do Not Resuscitate/Allow Natural Death paperwork that I would sign and I left the room to go find her family and to give her daughter in room 45 an update on her mother.
The entire family gathered round as I explained all of Mrs. Mitchum’s injuries and that though minor for a younger person, these same injuries could prove to be too much for an elderly woman. I then explained the ‘questions’ that I had asked and the answers she had given. Hesitantly, I asked the family if they would be willing to support her in her decisions.
To my great surprise, they explained that Mrs. Mitchum was a strong woman with strong opinions, a family leader, having lived independently up until now. They agreed to support her and to honor her wishes. That “they’ did not include the 30 year old angry grandson who came bursting through the doors of the ER at just that moment…
“Where is my grandmother?!?!” I heard him yelling coming down the hall. “I’m going to kill the man who did this to her!!! That drunk driver is going to pay!!”
Family stopped him outside of her room, trying to calm him. I saw one of the family members motion for me to come over. “Please talk to him and tell him what is going on and what we have decided.”
I tried. I explained her injuries and my concerns. Then I explained her wishes not receive any forms of artificial life support. This led to his emotional explosion.
“No, doctor, you put her on life support if she needs it, you hear!” That is my granny in there and I am not going to let her die!” he roared, his whole large frame visibly shaking as he stood before me, just inches from my face.
I gulped and tried to calm him, “This is her decision, not yours or mine, to make, sir.”
He pushed past us and into the room. I followed on his heels.
“Granny”, he burst into tears, “I love you so much. I’m so sorry this happened to you, but you had better not let go, you hear!. You are strong, you need to fight this! We take care of each other don’t we? Please don’t give up on me!” He was sobbing loudly and she sat herself up in the bed to comfort him. She sat up very straight and held herself as tall as she could, her stature containing remnants of the woman who had held this sobbing giant as a baby and who had led him by the hand as a child and chided him as a wayward boy. Now, she held him as a grown man, as best she could with her frail and now partially broken frame. “Granny you let them put you on a ventilator if they need to! If you die, I promise you I will kill that drunk driver myself. No one is going to hurt my granny and get away with it!” he called out from a place of pain and helplessness.
“It’s OK son. Your Granny will be OK.” She said with perfect peace as he shed the tears that only a grandson can.
Later, she refused to be put to be put placed on the ventilator even for the broken hand and foot to be fixed surgically. She, more than any of us, could see the forest and was not worried about the trees. She was delivering us the message, while we doctors could not get over the package.
On the second day of her hospital stay, she entered an “unresponsive state”. Any good doctor feels that it is his or her duty to ‘identify the problem,’ to figure out the organ dysfunction, to analyze the wrapping of “the package” under a microscope or with a special procedure or test. So, a neurologist was called in to identify the reason for the ‘unresponsive state’. An EEG was done to analyze her brain activity. Mrs. Mitchum had entered a seizure state that kept her unconscious. Feeling compelled to “do something”, the doctor ordered an anti-seizure medication to treat the ‘brain dysfunction”—like almost all doctors would- yet focusing on the trees and not the forest, on the organ and not the person, on the package and not the message found within. This was the last cure-focused treatment she received. Her family honored all of her other wishes.
4 days later, Bonnie Mitchum passed away, peacefully, much on her own terms. No ventilators, no surgery, only after she was unconscious was she given a medication treatment in attempt to ‘fix’ her. Otherwise she was kept comfortable by a loving team of trauma doctors and nurses who were all willing to step outside of their usual roles (fix the organ, fix the problem) and allowed death to arrive, naturally, as desired by Mrs. Mitchum and most of her family—in a package of just a few broken bones.
Monica Williams-Murphy is an emergency physician and author of It’s OK to Die.
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