January 28, 2014

May Die Tonight

Her room is at the beginning of the hallway into the hospital ward.  You might think this is a noisy place to be, but it is actually the opposite.  A long expanse of administrative offices provide a sound break between the elevators and the rest of the rooms beyond hers.  Further into the ward is the nurses' station, which is full of bustle and paperwork and ringing phones and vacuum-tubed medications at all hours of the night.  But the beginning of the hallway is calm and quiet.  It is the best place for her to be.  The small, square magnet on her door frame has a blue background and a white tree, a subtle sign to anyone who enters that the patient inside is dying.

I helped admit her when she first came in, with septic shock from an infection, but especially ill because she had metastatic cancer that had immobilized her gut, altered her urinary tract, and prevented her from eating.  She was in pain and clearly uncomfortable.  Her mother was a dominant force in the room, giving us the history and settling her in.  It soon became clear that the patient and her family were devoutly religious, and hoped she would be healed in a miracle.  She was only on our floor for a few hours before we transferred her to the ICU.

We followed her course from afar, knowing that if she survived long enough to leave the ICU she would return to our service.  We read about how she broke a bone just by repositioning herself on an x-ray table, because the cancer had riddled every part of her body.  We read the notes of the music-thanatologist (someone who studies death), a harpist who played bedside music in vigils that provided comfort for the patient and her family.

When she came back to us, she was in worse shape but the focus had shifted from treatment to providing comfort and pain control.  After a week or so with us on the floor, she began to weaken, as we had predicted would happen.  The cancer was too voracious; every day became a waiting game.

Each night, when our team would "sign out" our patients to the overnight doctors (give them a brief overview of each patient, with instructions in case of any overnight issues), we wrote at the bottom of her note: May Die Tonight.  We added it when her breathing had become labored, with pauses; however, we had underestimated her strength.  Each day, the footnote remained the same.  It was intended as a warning, a small heads-up for the covering team that they might want to be certain of how to pronounce someone dead, of which forms to fill out, of what kind of documentation would be required.

As the days went by, however, it became clear that "May Die Tonight" was more of an aspiration than a warning.  I found myself dreading and yet needing to visit her room each day, wanting to be available for her mother and family but uncomfortable at the way her death reflected my own mortality back at me.  I dreaded the daily toll of being frank in the face of her mother's continued (but diminishing) optimism -- or was it purely denial by now? -- that a miracle would occur.  I dreaded the strong memories of my grandmother's death a few years ago, a tableau of home hospice that prepared me for the stages of death as this patient progressed toward the end of her life.

Each night before bed, I would check the computer one last time to see if she was still living.  Part of me wanted to know so that I wouldn't be surprised in the morning; part of me was hoping each night that tonight would be the night, that soon my patient's pain and suffering would end and she would slip away to be with the Lord, just as she and her family believed.

It is a strange feeling to hope that your patient will die.

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