Fri 5 Mar 2010
I sit on my front porch, the smoke of a cigarette lazily curling around my fingers. I’m not a smoker, but from time to time I bum one off a neighbor when I’m feeling particularly stressed. An old habit from an old girlfriend.
My patient, Simon, is dying. Bacteria have riddled his body, already ravaged by chronic illness, and he has been dying slowly for months. Last week, with the input of his loving family, we withdrew all medical care on him, and I’ve been watching him die for days. This morning I heard the first telltale sign of the death rattle. I’ve never heard it before, but it is a chilling sound. The Reaper is standing in the room with me, and I can see his hand on Simon’s shoulder. I have been with death before, but not like this.
Simon’s room is beautiful, papered with carefully hand-lettered signs. “Simon, we love you.” “Go with God.” “Happy Birthday From All Who Love You”.
His brother, Joseph, approached me today. Joseph and his mother are concerned that by not giving Simon fluids by mouth or IV, we are making him less comfortable while he dies. From a purely medical standpoint, I know this isn’t true – at this point, hydration will only cause his lungs to exude more fluid, drowning him in his own secretions. He’ll be far more comfortable without, but I couldn’t find a way convey this.
And then, Joseph laid his hand on Simon’s head. “I’m so sorry, brother. I love you so much.” Simon, who barely focuses on anything any more, turned his head to look into his brother’s eyes.
So I decided to take the middle ground. I started extremely low-dose IV fluids – so low that I hope it won’t make a difference – and increased the pain medications in case it makes him more uncomfortable. But I know full well that more pain medications will hasten his death by decreasing his drive to breathe. He’ll die faster now, and that decision must stay with me.
I sit on my front porch, the burden weighing heavy on my shoulders. Joseph and his mother may sleep easier tonight, believing Simon to be more comfortable, but I won’t.
I just sit, and watch the trail of smoke drift up towards heaven.
I’ve never found the decision towards withdrawing care and allowing a patient to die an easy one. Sure I believe that people need to be allowed to die, and often a lot sooner than others, but the deliberate nature that we, as physicians, have with pain medications, reduced fluids/ nutrition, etc seems contradictory to what we believe we’re supposed to do. It was troubling to see how a dying patient was given increasingly larger doses of narcotics in an ICU when I was an intern. It’s still hard to be the one to increase those doses as the upper level resident, because you feel that you’re killing the patient. It gets a little better, but it still doesn’t set well with me.
“Medication may be mercifully administered to me to alleviate suffering, even though it may hasten the time of my death.”
–Clause from a sample living will
I do the same thing with the cigarettes
I think I should take up this occasional cigarette habit. The last hours and days never seem to rest easy on anyone’s mind…often we seem to land up making fraught decisions when perhaps letting go is the fairest but the hardest decision to reach…it’s tough.