ESSAY ON BEING A DOCTOR
The Best Medicine at the End of Life
Ryan Gravolet. The Best Medicine at the End of Life. Methodist DeBakey Cardiovascular Journal. April 2015, Vol. 11, No. 2, pp. 151-152.doi: https://doi.org/10.14797/mdcj-11-2-151
I will never forget her eyes, sunken and dimly lit with the dying embers of hope. She was scared, exhausted, and wildly scanning the room filled with doctors, nurses, and hospice workers, looking for reassurance and any good news we could provide about her husband. Looking for a friend to say this was all a big misunderstanding. The young woman sat and waited for the emergency medical meeting to begin, desperate to know the prognosis.
Just 3 days prior, her perfectly healthy 39-year-old husband suffered a massive heart attack and was rushed to Houston Methodist Hospital in an unconscious state, precariously positioned on a thin ledge between life and death. After multiple operations, he landed in Bed 1 of the Cardiovascular Intensive Care Unit with all eyes on him. The medical team included cardiothoracic surgeons, cardiologists, pulmonologists, intensivists, and nephrologists who did everything possible to preserve life: two mechanical heart pumps, maximum doses of intravenous pressors, full ventilatory support, and continuous dialysis. But the patient was not getting better and remained in severe heart failure.
Heightening the challenge of an end-of-life discussion, the young woman spoke little English. She and her husband emigrated only months earlier from Vietnam, and they had been in the midst of their happiest days. A new baby due in 8 weeks. A new business. At a time when the photo albums would be overflowing with life’s milestones, the young woman sat around a circle of strangers pleading for good news through a translator.
After introductions were made, the young woman’s attention focused on the attending physician, and the meeting began. The attending spoke, “Thank you for meeting with our team today. As you know, your husband had a large heart attack, and we are doing everything we can to keep him alive. Unfortunately, his heart is failing and not showing signs of returning function.” We watched her as the translation was received.
She leaned forward expectantly, not fully certain of the news, and her expression pleaded for more information. Her voice trembled as she struggled to say, “But he can recover….”
A slight pause, and the attending continued. “I am sorry… but the chances are very low.” The room held its breath. “He is dying.”
Her gaze dropped and the last flicker of light went from her eyes. No translation was needed for the immense pain she felt or the heavy cloud of silence encasing us all. No words could break through and interrupt the moment she was coming to understand her husband would die. The veil of secrecy had been lifted, and she was now confronting the horrible truth we all knew and shared.
The question she had spent the last three days gnawing over had been answered, and she quietly sobbed. After a few minutes, she bravely collected herself and addressed the team.
Armed now with expectations and an appreciation for the grim prognosis, she spoke freely and thanked everyone profusely for helping her husband and supporting her. She thirsted for more information and trusted the team with many more questions: how this could happen; how we were certain and if he had any chance of pulling through; how much time she had left with her husband and whether she could stay with him past visitation hours.
The wall between family and medical team was demolished because of the shared understanding of prognosis, and different members of the team could answer her questions honestly and directly. The cardiologist informed her that no one could have predicted this tragic event in a healthy man this age. He thought there was less than a 5% chance of the heart surviving the week. The intensivist promised her that no one would ask her to leave her husband’s side at any time. The palliative care team offered their advice for getting family assistance, ways to break the news to her own family, and alternative perspectives regarding her new baby, which could be the blessing to help mend her broken heart. She was encouraged to sit by her husband now “to say everything in your heart, to say everything that needs to be said.”
The young woman listened intently, noticeably calmer now by having more information and the near certainty of death. She signed a DNR order to avoid further suffering. She left the meeting and went to sit beside her husband, savoring the time and opportunity for closure of an episode she would undoubtedly relive for the rest of her life. She cried more, but the terror of the unknown was gone.
One of the biggest temptations in medicine is offering false hope; we often believe that good news builds trust while bad news alienates us from our patients and our very purpose of treating people. Prognosis is sometimes guarded, and the process of dying can be kept secret. But the hubris of promoting an unlikely turnaround robs patients and families of the opportunity for closure and quality moments together in the sunset moments of life.
Sadly, our patient died the day after the meeting, but I’m confident he would approve of how his wife was spoken to and treated. Providing an unambiguous prognosis allowed her to cross the threshold and begin her grieving. The young woman sat beside her husband and held his hand with understanding of the significance of their final hours together. What better medicine is there at the end of life?