Note to My Patient
You might be surprised to know that I'm lying here in bed still thinking of you two weeks after you've died.
During the month that I watched you die, I often wondered what it felt like to be you, with your deep, husky voice, rounded belly and stubborn anger. You'd once owned your own mechanic shop; now you were sitting here in a hospital bed, staring up at the medical team as we whirled in and out of your room. Staring up at me as I drew blood from your central line each morning.
Some days, I forced myself to make the whirlwind stop. I'd sit in the chair across from your bed and ask you what you really knew about your cancer.
You'd look at me and say, "Not this again."
Your cancer, originally only in your bladder, was everywhere now--in your colon and your bones and your lungs. You had fevers now, too; they kept on coming and kept getting higher, bringing with them the highest white-blood-cell counts we'd ever seen. I wanted to talk to you about your options--whether to sign a Do Not Resuscitate order, whether to go on home hospice, whether to keep trying to figure out where the fevers were coming from.
Those conversations about your cancer always ended the same:
"I want everything done," you'd say.
I'd set off again to page the infectious-disease team, to see what tests and scans they wanted us to order now. You got the MRI, the sonogram, the CT scan, the blood smear for babesiosa. We ruled out a hospital-acquired intestinal infection four times.
And nothing changed.
You were so angry. I knew you didn't want to die, and that you couldn't yet believe that no matter what we did, the end result would always be the same. Your wife, emaciated with her own disease, came by every three or four days to see you. Your daughter would come up from Philadelphia, too, to visit you when she could; and in your laughter and your family's concern, I could see remnants of the father and husband you'd been.
One morning, you refused to let me listen to your heart and lungs.
"You're just waiting for me to die," you said accusingly. Then you stopped and stared at me.
"My roommate Sam died last night," you said. For the first time, your eyes held deep sadness and resignation.
Then, one Sunday, when your blood count had dropped low enough for another blood transfusion, my fellow resident Ben and I had to guide your hand through the informed-consent document that would allow you to have the blood.
I sat on the edge of your bed, and you could barely keep your eyes open. I asked you again about whether you wanted the chest compressions and the tube down your throat; and for the first time, you asked what would happen if you did end up on the ventilator.
I felt Ben, standing next to me, take a deep breath.
"You'll probably never come off of it," he said.
You thought about it for a minute. Then you stared coldly at us.
"Do everything," you said.
It was time to sign out to the night team. I left the hospital to go to the gym. I felt so angry at you; as I worked out on the elliptical, I was mentally performing chest compressions over and over.
Overnight, though, you got weaker. I didn't have to beg you to consent to your morning blood-draw. And when you tried to shift from your bed to the chair next to it, you fell. As the nurse and I pulled you up from the floor, I felt how heavy and helpless your body was. It had no strength left.
A few days passed.
"I'm in pain," you said for the first time. And you agreed to take the morphine.
Now everything had changed; and yet we were still preparing for the day when your body would fail you, and we would need to restart your heart and control your breathing with a ventilator.
Then the day arrived when your blood pressure kept dropping and your breaths gradually came more rapidly. A code was becoming inevitable. We were preparing to put in a new central line so that we'd be able to funnel the needed drugs into your body.
"I don't want it," you said. "I just want this to be over."
All I felt was immense relief. As Ben and I watched, you slowly signed the Do Not Resuscitate/Do Not Intubate papers. It made everything so real.
You seemed so defiant in that moment. It was as if you were taking control in the only way that you could--by choosing how you were going to die.
A week later, you died.
During that final week, you slowly stopped talking, and your eyes became fixed on something that I could not see. Your cheeks grew hollow, too. In the mornings, I would rest my hand gently on your chest, feeling the feeble thud of your heart and the rattle of your lungs.
On your last day, Ben and I were called into your room to see if you were still alive. Your pulse was fading, and your chest was no longer moving.
We attached you to the leads of the EKG machine. Your skin felt so empty under my fingers; I couldn't bear to look at the flatline on the screen in front of me.
We left your room. I chose to remember you the way you used to be, long before I'd known you.
I called your wife, not troubling to mask the sadness in my voice; Ben called your daughter. Your family was heartbroken.
And then Ben and I sat beneath the fluorescent lights of our team room and cried. In that moment, we were completely overwhelmed by the humanity of medicine--by the fragile vulnerability at its heart. I realized that I knew so much about how you had died, but so little about how you had lived.
That night, as I walked the dark autumn streets of the Bronx from the hospital to the gym to my apartment, I tried to find peace in the loneliness that comes after a death.
I tried to feel alive.
About the author:
Sarah Eisenstein Stumbar is an intern in family medicine at Montefiore's Residency Program in Social Medicine in the Bronx, NY. She believes deeply in treating patients as whole people, seeking to recognize the multiple contexts--including family, community, culture and language--of their lives. "I started writing book reviews for a children's magazine when I was five years old. Since that time, writing poems, short stories, essays and letters to the editor has evolved into an important part of my personal and professional life. I write to be an advocate and voice for my patients, but also to recognize my own experiences and commitments in medicine."