I am a nocturnist (a nocturnal hospitalist). I love my job, but many nights my work can seem unfulfilling. For one, taking care of hospitalized adult patients is primarily spent managing exacerbations of chronic diseases. Therefore, the reality is that most patients will not be cured, only managed. Additionally, there is the loneliness factor, the incessant beeping of my pager, and the fact that I am forced to disturb the slumber of a consultant if I need help. But on one busy night, I experienced fulfillment in, paradoxically, the death of a patient.
It was midnight. I had seen four or five patients and had several more to see in addition to fielding a battery of pages from the floor. I recall hurrying everywhere, and when I reached the top floor of the hospital via the stairs, I was short of breath. I was going to see an elderly patient sent from a nursing home with an elevated sodium level, which is not an uncommon scenario. “Please talk to the family about code status” the patient’s nurse greeted me with.
When I entered the room, there were a man and a woman at the bedside. The patient was an elderly female who was squirming uncomfortably in the hospital bed. I introduced myself to everyone and deciphered quickly the patient either had advanced dementia or was delirious. She did not look at me when I called her name. Her eyes darted to and fro without fixating on anything in particular. She was cachectic and did not speak. The man was the patient’s son, and the woman the daughter-in-law. They explained to me the patient was sent from her nursing home after blood work revealed the elevated sodium level. I had reviewed the patient’s labs earlier when the ED physician called me – her sodium level was 175, and she had a profound acute kidney injury, in addition to other metabolic disorders. The family confirmed the patient was diagnosed with dementia many years ago and recently was barely eating or drinking despite encouragement from them and nursing home staff.
At this moment the patient’s clinical course could have gone in one of two directions. It would have been straightforward for me to pass the buck to the physician taking over the next day – no one would have faulted me for that. I was tired and had more patients to see. My pager went off again, and I reached into my pocket to silence it. I could have explained, “Your mother is very dehydrated – we will give her IV fluids slowly over the next few days to correct the sodium level and improve the kidney function.” But instead I felt I should ascertain the family’s understanding of the patient’s condition, so I sat down in a chair and faced the son and daughter-in-law. Over the next 30 minutes, we talked about how their loved one had been progressively deteriorating – she was bedbound, did not speak, and could not feed herself. The family knew she had dementia but appeared to be unaware that her condition was advanced – no one had ever explained to them she was dying.
Ultimately, when it came time to discuss the plan of care, I recommended supportive care alone. I advised against further blood draws, advised against any further imaging studies, advised against antibiotics, and I did not recommend pursuing placement of a feeding tube for enteral nutrition. The family agreed. They asked me how long I thought she would live and I offered a rough timeline of days to weeks (at best). I offered analgesia given the patient appeared uncomfortable and encouraged the family to feed her anything she liked if she wanted to eat or drink. I recommended the patient not undergo CPR or intubation if the clinical circumstances dictated such measures, explaining that these would not improve their loved one’s quality of life. We discussed having our hospice team talk with the family in the morning.
I sensed a weight was lifted from the family upon hearing my recommendations – suddenly it wasn’t as if they were letting their loved one “starve to death” (I educated them on how this wasn’t the case) – the burden of making these types of decisions was transferred to me.
Six hours later I received a page asking to pronounce a patient who had died. Incredulously, I looked at the room number and realized it was the elderly lady from the nursing home. When I arrived, the family was standing near the bed, their eyes glistening with tears. I expected them to be angry, so I was prepared to be berated. I imagined them screaming “you told us she would live for weeks!” With my eyes averted, I softly offered condolences and apologized for my inaccurate prognosis: “I’m so sorry, I did not expect her to pass away tonight.”
The son looked at me and immediately replied, “Oh no, don’t apologize – this has been a wonderful experience, and we thank you for helping her to pass away peacefully and with dignity.”
Images of death in hospitals often include chaotic scenes of CPR, mechanical ventilators, lines, tubes, and blood. Leaving this world in a hospital can be painful, cold, and degrading. But on that night, there was a peace that came from a death on the wards. As I wrote the expiration note, I reflected on the events and felt good about what had transpired. Suddenly, a loud beep cut through my soft keyboard strokes: the pager. I looked down; the emergency room was calling again for another admission.
Scott Keeney is an internal medicine physician.
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