i can't count the number of patients i've taken care of during my last two years of residency who i've had to declare. i could probably contact the department of health and ask how many of my signatures litter the bottoms of death certificates, but this wouldn't get at what i'm trying to express. the fact is, although i secretly cry every time i place my stethoscope on a chest and hear no heartbeat, i don't always have the time to really process what has happened. there's an aching, empty feeling in my soul that insists that i mourn, but often a louder, tangible, set of duties i have to fulfill that keep me from responding. the tears often come later, at home, under my covers as i drift off to sleep after a grueling 16- or 27-hour shift. this was especially true recently when my overnight admission (on a night i was covering) died unexpectedly prior to morning rounds. she made a profond impression on me and i offer this that follows as a celebration of her life and for my own mourning.
of all your glorious 95 years on this planet, we only knew each other for the last 9 hours. it seemed like longer than 9 hours, didn't it?
we first met in the bustling, chaotic cave known as the emergency department. it was 11:30pm. you had been there all day; several doctors had seen you and given you various treatments and diagnoses. i spotted you from afar: you were sitting on the edge of your stretcher, beaming from ear-to-ear, jabbering on with your son at your side. you took my introduction as your cue for a big, welcoming hug punctuated with a sloppy kiss on my forehead. i was instantly infected with your enthusiasm.
how did you feel, i asked. "like a bullet!" you told me in spanish, "better than ever" and "wanting to go home."
you had so many medical problems; only a few months prior you had been ill and admitted in this hospital. although you're weren't in eminent danger of dying then, the overall prognosis was abysmal. you had been discharged to an inpatient hospice with round-the-clock care. as a testament to what i was already experiencing as your insatiable appetite for life, you did so well in the hospice you were discharged home into the care of your 3 generations of offspring.
but here you were, with the vague and initimidating Shortness of Breath and exponentially complicating Chest Pain. you had abnormal labs and evidence of an ongoing mild heart attack. your kidneys weren't working very well. the plan for these problems several months prior had been "keep her comfortable." and i could see why: often doing invasive tests and procedures in a 90+ year-old can lead to worse complications and suffering. in fact, you had already decided to be "DNR/DNI" which meant that if your heart stopped or you stopped breathing we wouldn't do chest compressions or put in a breathing tube, a really thoughtful and appropriate decision.
i admitted you to the ward. i spent time at your bedside, re-examining you, trying to help treat your pain. i repeated your bloodwork: it hadn't much changed. i talked to the covering cardiologist. i dosed medications. what did you want during this time? "cafe con leche, doctora." your nurse, a wizard in her own right, found the last cup of de-caffeinated coffee in the hospital and we plyed you with it -- only after, did you finally opt to sleep.
i checked in on you several times thereafter and you were sleeping peacefully. at 8:30am, i stopped by to let you know i would be handing off care to the day doctors. you gave me a giant hug and thanked me profusely; i sat down at the foot of your bed and listened to a story about your oldest son who would be coming in later to visit. would i call him for you, you asked? would i tell the day team you could go home today? i assured you i would heartily suggest it.
waiting to present to the team, i lounged on the couch in our resident lair. my waist buzzed at an incoming text page: "patient expired. please come." i rubbed my eyes. wait, what? i thought. did i read it correctly? did patient's ORDERS expire? my movements came quicker than my thoughts -- i ran down the hall to your room. i found a frantic site: a rolling blood pressure machine hooked up, an NP, a resident, several nurses and my patient's nurse all standing around her bed. "what's going on?" someone belted across the room. "who's this person's doctor?" another near her chimed in: "i think she's DNR?"
i sprung into emotionless action as i've been trained to do and took over the situation. i shooed people away; yes, she was DNR/DNI i answered. yes, i could handle it from here. i moved towards your lifeless body, eyes closed, skin cold. i placed my stethoscope on your chest: no heart beat. no breathing. the silence contrasted sharply against the barage of thoughts parading through my mind at that moment. my overwhelming sense of inadequacy was embarrassingly at the forefront: what could i have done to prevent this? nothing, i realized. it was your time. your body finally gave out and i'm glad it wasn't before one last cafe con leche.
rest in peace, mi amor. you are greatly loved by generations, including this young doctor-in-training who could not resist your enthusiasm for life. you truly got your wish after all: you went home that day.