Goodbye From the ICU
Andrew R Carey
I do not know this man. I have never met him. All I know about him are the words typed in his medical chart--and that, before the day is out, he will die.
I have never heard him speak. I probably couldn't pick him out in a crowd. Today he looks like a water bed: yellow, warm and squishy.
I wonder if he ever pondered what his last days might be like. Surely he hadn't thought that at age forty-five he'd succumb to the final stages of hepatitis C, a disease he probably never knew he had. He's been in this Boston ICU for forty days, idling under the cautious vigil of interns like me, doctors fresh out of medical school.
I have met the man's mother, a small Puerto Rican lady who has the stereotypical osteoporotic dowager's hump and always wears a decorative shawl over her head; we've spoken a number of times.
On this bitter December day, it's been my profound duty to inform her that, despite our best efforts and elaborate technology, her son is still getting worse, and that in fact there is nothing we can do to save him.
As we talked, I paused often, she cried much; I held her hand. She struggled to ask me if it was these machines that were keeping him alive, then surmised that there was not much point in prolonging the suffering.
Gesturing to the beautiful afghan that she'd knit, which covered him in his hospital bed, I said, "Do you want us to make him look at home as we turn off--"
"I don't want to be here when he dies," she interrupted, her words barely audible through her tears. "My heart just couldn't take it."
My heart sank. How could any mother's heart take it?
This pain that plucks at my heart is the doctor's unspoken burden. To let it out would be to acknowledge my deepest fear: that I have failed my patients. I rarely discuss it with my colleagues and never dare to broach the subject with those outside these walls.
I remember sitting down to my first Thanksgiving dinner as a medical student and spontaneously remarking how much the turkey leg reminded me of my anatomy cadaver's arm. No one else seemed to find the comparison interesting or humorous; that was the last time I shared my thoughts about medicine with my family members. Instead, I shelter them, believing that it is the doctor's duty to prevent pain and suffering; and I secretly hope that their warmth and lack of awareness can help repair my heart.
Dying is not always scary; often, it is a welcome end to a life well lived. It seems most patients know they're dying before the doctor ever opens his mouth. Almost universally, my patients want to know what the end will be like. Their heads flood with scary images of their unknown yet certain future. Will it hurt? Does it feel like suffocating?
I imagine that worst of all is the fear of being alone--feeling unloved, feeling inhuman; hooked up to cold machines with bells and whistles rather than feeling the warmth of a loved one's presence.
I like to think there's such a thing as a good death--one that takes place at home, surrounded by loved ones, with minimal suffering for patient and loved ones alike.
But we so rarely achieve the good death in the hospital, or even come close to it.
Perhaps this is because we fight so hard to save our patients. So often, it seems, we forget our most basic principle:primum non nocere--first, do no harm.
The truth is that often our patients have passed long before they die. We keep them alive so that their loved ones can come and see them, say their last goodbyes. Sure, there's a heart beating and blood flowing, there's air moving in and out of the lungs; but the person they love is gone. What lies before them is an empty body.
Even knowing this, my soul still aches each time a last breath fades away and a heart goes silent. It is the finality of the event. There is no coming back, no organ left for denial to hide in.
And this man, my yellow man, will not die the good death. The best we can do is to try to save what dignity is left.
To continue life support and use "heroic" measures would sentence him to a slow and gory death. His blood, thinned by his failing liver and oozing from every orifice, would squirt across the room with each futile compression of his heart and pulse of electricity aimed at shocking his body back to "life."
Instead, with his mother's consent, we will remove the ventilator and allow his lungs to fail because his brain cannot tell them to breathe.
Quickly and peacefully his blood will run out of oxygen and bubble with acid, his heart will cease to beat, and the few remaining signs of life will disappear. What's left of his light will flicker and disappear from this earth, without anyone who ever knew its warmth to watch it go.
This abrupt confrontation with mortality that I've been avoiding sends chills down my spine. Is this what lies ahead for me?
For now, I am left with this man I do not know, to keep what is left of him company, to tell the story of his final hours.
About the author:
Andrew Carey did his internship in internal medicine at Boston Medical Center and is currently doing an ophthalmology residency at the University of South Florida. "I became interested in writing to help work through conflicting feelings. In medical school, it really helped me cope with sick and dying patients. I hope my writings can help others in the profession recognize that they're not alone and enable them to take better care of their patients and themselves."