The sign-out note from the previous doctor reads, “Daughter and son-in-law from out of town, we met multiple times last week to discuss goals of care.” As his medical decision-makers, they’ve been waffling about what to do for him. Last week, they said, “Do everything,” then, “Take a comfort approach,” only to wind up back with, “Let’s get him strong enough for rehab.”
I’ve been putting off checking on him: afraid his family will hijack the visit by changing their minds again.
Walking into his room, I’m struck by its sharp contrasts. The daughter and son-in-law, wear designer black, with Apple watches lighting up their wrists. They peck away on their iPhones and laptop. All week, they have been working from a cramped room with its 1980s decor. About the only color in the room is the patient’s maroon VA-issued pajamas.
I introduce myself, but don’t engage in lengthy conversation — not yet.
As the morphine wears off, the patient awakens to his own drowning: Gurgling secretions fill squishy lungs. Too weak to cough, he grimaces, large eyes pleading for help. The nurse and I reposition him. Another dose of morphine helps with his air hunger, and he drifts off again.
Throughout the morning, I check in on him. The son-in-law paces; his daughter types on her phone. Both seem absorbed and distracted. I wonder what it’s like to lose a parent, then quickly shut out the thought.
About midday I ask them, “How’s he doing?” I know the answer: Comfortable for now, but what about when he wakes up and can’t breathe?
I suggest that we step outside to talk about what’s next — specifically, the father’s impending death.
“He was doing so well last week,” his daughter says. “I guess we thought he’d just walk out of here.” She’s hopeful.
“We know he’s tired. We can tell he’s given up,” her husband says. And then, “Do you think he can recover?”
Their faces give away their thoughts: How long does he have? If we remove the oxygen mask and let nature take its course, would he suffer?
I take a breath, quieting my own feeling of loss over this patient’s future.
“Your father sounds like an exceptional man,” I say. “Can you tell me more about him?”
They go way back, filling me in on his military service, his love for music and dancing, how he met his daughter’s mother. About his beloved garden; he gave away everything he grew. Moving into the present, these two middle-aged adults agree he wouldn’t want to live like this.
We discuss what happens next — the mechanics of managing his symptoms without prolonging suffering. Mostly, they ask me questions I can’t answer.
“How long will it take for him to die once the oxygen is turned off?” I’m not sure.
“Can he feel anything?” Not sure.
“Can he hear us?” Don’t know.
This man is her father, and my patient: I want to get this “right.”
“We want him to be comfortable,” his daughter says through tears.
“So do I,” I say. I try to seem stoic, but my heart races. Although I’ve attended many deaths, this is only my second time removing supplemental oxygen — a “terminal wean,” as it’s called.
Before going back to the patient’s room, I approach his nurse.
My check-in is blunt. “Have you ever seen someone die?” If she feels moral distress over weaning the oxygen, I need to find another nurse to assist me.
“Once,” she says.
“Me too,” I want to say, but don’t. I feel exposed, like I’m playing doctor instead of being one. My mind races: Will I be relieving his suffering, or actively killing him? Does anyone die well, or are we just kidding ourselves?
Too chicken to share these thoughts, I ask, “Are you okay assisting me?”
“Yes,” she says. Suffering my own moral distress, I’m not sure that I’m okay doing this.
Should I sleep on it? Maybe I just wait till next week, sign it out to the next hospitalist? I wonder.
He won’t survive until next week, my mind reminds me firmly. Be the doctor.
I blink hard. I have to get moving.
The nurse and I go in together. Tall and blonde, she projects the poise and confidence I wish I had. She’s holding two syringes: one in her right hand, to sedate; one in her left, for air hunger.
“This is the right thing to do,” she says, as if to tell me: You’re not an impostor. You belong here. You can do this. “He’s suffering, and we have to help him.”
She turns off the fentanyl drip and injects each medication. I make the first downward adjustment to the high-flow oxygen, and we watch.
Lungs gurgling, our patient remains in an opioid dream. Across the bed, his daughter holds his limp hand.
We’ve each staked out our territory and purpose: the nurse gives medications, his daughter has a hand, I have the oxygen, while the son-in-law paces. Perhaps needing more, I lean over and push my patient’s stick-straight hair toward his right-sided part, wondering, Did he consider himself lucky to have this full head of hair?
Over the next 30 minutes, I gradually turn down the oxygen until the machine no longer hisses. He holds his breath — and so do we. When he finally exhales, it’s a sputter, while our collective in-breath is deep and full.
I feel for a pulse. Nothing.
His daughter looks at me. Is he dead? her eyes ask.
I walk around to her side of the bed, her face splotched red from crying, her hands firmly clutching shredded Kleenex.
We embrace. I feel a lump of emotion stuck in my throat. My eyes fill with tears that I don’t let fall.
It’s an honor to be part of this veteran’s death, I remind myself.
“He died well,” I hear my voice say, mechanical and far away.
Next comes a blur of paperwork: death note, organ donation, consent for autopsy.
Casually, I ask the nurse how she’s doing.
“Fine.” Maybe sensing my distress, she says, “He was suffering. We did the right thing.” Then she hands me the death certificate. “Could you sign on this line? No, not there, here.”
Time of death. Cause of death. Did tobacco contribute to death? It’s comforting to be able to work again. I’m focused and productive. Tasks getting checked off.
Why is doing task-oriented work easier than being a witness to suffering? I ask myself. Why is standing silently at the bedside to comfort a patient or family member so exhausting? Shouldn’t it be the other way around?
It’s been 12 hours since I walked into the hospital. I head back to my office and scoop up my belongings. I hit the lights — and then it hits me.
In the dark, I slide down the heavy metal door and land seated among my car keys, handbag, water bottle and a mostly uneaten lunch. Knees tucked under my chin, I sob.
“I just witnessed a person die,” I whisper. Questions tumble through my mind: What about me? What about my distress? Does being a physician mean that I have to be an emotional robot? Why couldn’t I share my vulnerability with the nurse? Why are we taught that showing emotion at the bedside is weak? Would I lose my respect if I was respectfully authentic? Would it matter?
I take a few breaths.
Take it easy, I tell myself. It’s only Monday. You have another six days on service.
Gently, I remind myself that when I miss a chance to practice self-compassion, I get one more chance — and then a thousand more.
Tonight, in the dark, is my one more chance.
Amy Cowan, an assistant professor in internal medicine at the University of Utah, practices as a hospitalist with the Veterans Affairs facility in Salt Lake City. This article was first published on Pulse, voices from the heart of medicine, a site devoted to personal stories about health care.