Nadine Semer ~
"She doesn't like vanilla," Mr. Wyatt says, staring at the nutritional drinks sitting on his wife's bedside hospital table.
I'm here as the palliative-medicine consultant. As my resident Susan and I stand still, taken aback, Susan's expression says it all: She's dying, and her husband is worried about which flavors she likes?
Mrs. Wyatt, fifty-six, came to our urban hospital's emergency room with abdominal pain. She was admitted and given intravenous fluids and broad-spectrum antibiotics. Her workup revealed widespread, untreatable cancer. Her medical team has consulted us because they're frustrated at her family's unwillingness to acknowledge that she's failing.
"Explained her poor prognosis; she needs to be DNR," read the consult request. "But still, the family wants everything done."
When we first saw her, Mrs. Wyatt was delirious and unable to talk. After reviewing the medical record and meeting with her husband and family, I could see why they wanted everything done. On one hand, her doctors had explained her prognosis; on the other hand, they were recommending more tests and aggressive interventions, and they kept adjusting her antibiotics. It seemed to me that they'd been addressing items on Mrs. Wyatt's "problem list" without telling her family how little their interventions could help, given her cancer.
"How was Mrs. Wyatt doing before she came into the hospital?" I asked her family.
"Aside from the pain, she was doing fine," said her youngest daughter.
With some gentle probing, they admitted that "her clothes have been getting big on her" and that she hadn't been to church in a while, or played with her grandchildren like she used to.
"I guess something has been going on," Mr. Wyatt finally admitted. "But she's not one to complain. She played down everything, until this pain came on."
They regarded one another silently. Then Mr. Wyatt said, "If she just gets enough to eat, we know she can get better. She's in God's hands: He'll take care of her. But she needs to eat."
After suggesting that they bring in Mrs. Wyatt's favorite foods, and expressing the hope that her delirium would lift, we tactfully reminded them that the cancer was the underlying cause of her deterioration. They seemed appreciative of our visit, and we agreed to talk again.
In the days that followed, my resident and I visited Mrs. Wyatt often. Sometimes she seemed comfortable, and we could chat briefly; other times, her delirium returned, and she seemed to be in pain, no matter how we adjusted her medications.
Then, last night, Mrs. Wyatt's breathing became labored, and her abdominal pain worsened.
I called Mr. Wyatt.
"We're worried," I said. "Your wife looks like she could take a significant turn for the worse."
Now Susan and I sit at Mrs. Wyatt's bedside with her husband and her sister, Julie. Mr. and Mrs. Wyatt are holding hands.
"Are you in any pain?" I ask her.
"No," she murmurs sleepily--but she looks uncomfortable.
"How do you think Mrs. Wyatt is doing?" I ask her husband and sister.
"Better," Julie says firmly.
"Why do you feel she's better?" I ask.
"She ate most of her dinner last night--the most she's eaten since she came to the hospital."
"I wish she were better," I say softly. "But I'm sorry to say that, based on her blood tests and overall condition, she's getting sicker."
Mr. Wyatt and Julie nod.
After a moment, I add, "Mrs. Wyatt is likely dying from the widespread cancer."
More silence. Mr. Wyatt stares at the nutritional drinks on the bedside table.
"How can she get better," he asks quietly, "when they only bring her vanilla? She doesn't like vanilla; chocolate is her favorite."
"We can arrange for her to have chocolate supplements," I say.
"And how can she drink more if they bring her orange juice?" he goes on. "She's allergic to orange juice."
I follow his gaze to the bedside table. There it is--an orange-juice box among the containers.
"I'm very sorry," I say. "We'll make sure that she gets the proper supplements from now on. But we're worried about your wife. And we're wondering what her wishes are for this stage of her care, so that her doctors will know which treatments she would want if she got sicker."
Again, we sit in silence. Mr. Wyatt gazes steadily at the bedside table.
Just then, Betsy, one of the aides, comes into the room. As it happens, she, like Mrs. Wyatt, is a grandmother of a large family. She and Mr. Wyatt have chatted about their grandchildren in past visits.
Her response is direct and perfect: "Why did they bring her OJ? It's on her record that she's allergic. And we have lots of chocolate drinks--of course she needs to have stuff she likes."
After gently patting Mr. and Mrs. Wyatt's hands, she leaves, taking the orange juice with her.
Mr. Wyatt stops staring at the bedside table and looks at his wife, who lies there, eyes closed, still holding his hand.
I try again. "Mrs. Wyatt is just not improving, and I'm worried that these treatments are causing her to suffer. If her condition continues to decline, she might end up in the ICU, on machines."
Mr. Wyatt and Julie gaze at me sadly.
"These treatments might prolong her life a bit," I continue, "but they do nothing to slow down the cancer. Is this how she would want to spend her last days? It doesn't have to be this way. We can change course and shift to care that would ensure that she's always comfortable for however long she has left, until God calls her home."
"Our Aunt Mary died on a ventilator," murmurs Julie. "You know, my sister never liked invasive stuff."
"We've talked about these things," Mr. Wyatt says. "Neither of us wants to die on a machine."
I see Mrs. Wyatt shake her head at the words "ventilator" and "machine."
I'm pretty sure that Mr. Wyatt sees this too. He squeezes her hand.
"The doctors are telling us you have cancer that can't be cured," he tells her. "What do you want to do?"
He mentions some of the possibilities: She shakes her head at doing more tests or putting in feeding tubes; she nods when he asks about increasing her pain medications. Silently, Mrs. Wyatt conveys that she wants to be kept comfortable, with her family nearby; she does not want to die on life support.
She dies a few days later, at ease, with her large family by her side.
As a palliative-medicine provider, I know how vital it is to validate the hopes and concerns of my patients and their families--and how difficult and elusive that can be. I'm grateful to Betsy for providing crucial assistance just when we were falling short. She was the right person and said just the right thing to help Mrs. Wyatt's family believe that her wishes, and theirs, would be honored.
This kind of care takes time...
And sometimes, a little chocolate.
About the author:
From a young age, Nadine Semer wanted to be a plastic surgeon. For fifteen years, she worked in a variety of clinical settings and spent time volunteering her skills in resource-limited areas throughout the world. "A few years ago, I realized that I'd become more interested in hearing my patients' stories than in performing operations." Having completed a fellowship in hospice and palliative medicine, she works as a palliative-care provider in a hospital on California's central coast. She's written two books--Practical Plastic Surgery for Non-Surgeons and Lattie's Run of Discovery (a children's picture book)--and has a blog, communicate2palliate.com.