Privileged #5 - Reconciliation

One of my most memorable patients from residency was a very pleasant lady in her 50's that I met for a total of 10 minutes. I was called down to the ER to admit her to the ICU, and when I arrived in her room, she was sitting in the bed, smiling pleasantly, with a pO2 of 30. She had been in the ER for several hours, and they were as shocked as I was when the ABG came back. Once we realized her situation, she of course turned blue and coded.

Once we got her into the ICU, it became clear to me what was happening: she was in neutropenic sepsis. She had just finished a round of chemotherapy and did not have a single white blood cell in her blood stream. Without an immune response, she had looked quite decent in the ER, until she suddenly and rapidly decompensated.

Her vitals plummeted. The ICU staff looked to me with that classic look meaning, 'How long as you going to torture this woman? When will you let her go?' so I told the staff up front: "We will keep going until her family arrives." And we did. For a couple hours, we got everything the ICU had: fluids, colloids, antibiotics, pressors... any and everything. We managed to keep her alive, but just barely so.

Finally, family arrived. Her sister was the first one to come. She went immediately to the bedside and started weeping. Gently, we described the situation to the sister: this lady would most certainly die. Then, we let her sit with her sister and ponder that horrible news.

Next came the patient's boyfriend. The nurse didn't think anything about ushering him into the room, but as soon as he walked in, an argument ensued. The sister barred him from the ICU room, and asked for security to escort him off the premises. Sadly, family squabbles make their way into the ICU all too frequently.

We brought the boyfriend to the break room while security was called, and I asked the sister to step out to the nursing station. We sat over some coffee. With all 27 years of my life experience, I tried to give the sister, who was easily double my age, some perspective.

"Your sister is not long for this earth. I have done everything I can do with medicine. There is no other drug I can give or procedure I can do. She is going to die.

"Now, you have the exceptional duty to carry out her wishes, since she can no longer speak for herself. No one asks for this job, but it's fallen to you, and I'm sorry for that. But please, whatever you may think of this man, whatever your beef with him, please remember that you are speaking for your sister. Please think, what would your sister want?"

The task of a health care proxy (DPOA-HC) is never easy. It looks simple based on the paperwork. It sounds simple to say that you'll speak up for a loved one when needed. But proxies are only ever asked to make decisions in the worst circumstances, at the worst times, when the choices are between horrifying and terrifying. And when you most want to have someone to talk to, a loved one to help guide you, that person is lying in a hospital bed, dying.

The sister flinched, and turned it over in her mind. She eventually relented, and let the boyfriend into the ICU room. They sat together in silence as we turned off the medications and the ventilator. They both wept openly as I came in and finally pronounced the patient dead. They took turns grieving, and finally stepped out of the room, hugging each other tightly, desperately clinging for support.

Before she left the ICU, the sister stopped at the nursing station. She thanked me, the man whom she will forever remember as the person who let her sister die. She thanked me because when most important, love will always be more powerful than hate, and love will always win.

This was the exact moment when I learned that being a physician often has nothing to do with any medical test or treatment.