Startled out of sleep, I reflexively reach for my beeping pager. For a split second, I lie poised between wakefulness and terror in the pitch-dark resident call room, not sure where I am or what happened. I resolve to sleep with the lights on from now on.
I dial the call-back number.
"Pod A," a caffeinated voice chirps. It's Candice, one of the nurses.
"Hi. Amy here, returning a page," I murmur.
"Oh, hi, Dr. Cowan," she says. "I just wanted to let you know that the family is all here. They're ready for the meeting." Her voice is sweet. At sixty-three, Candice is still practicing ICU nursing--at night, no less. She loves it.
"Candice, what are you talking about? What meeting?" I ask.
"They said that when you spoke with them by phone yesterday, you told them to come in. So they did, all of them. They drove up today, and now they're here, ready for a family meeting," she says matter-of-factly.
"Candice!" I hiss. "It's two o'clock in the morning. I'm the night resident. We aren't having a family meeting at 2:00 am!"
"Well, you did tell them to come in," she counters.
"Candice, that's what I tell everyone who asks if they should come to see a loved one," I say curtly. Truthfully, I've never met anyone who regretted coming in.
"The family must have misunderstood me," I continue, a whine creeping into my voice. "A meeting should happen in the light of day. With the whole team."
"The family said you're their doctor. They want a meeting with you," she replies calmly.
"I'm on my way," I mutter reluctantly.
"Great! They're in the conference room."
Her cheer only fuels my anxiety. I imagine tomorrow morning's sign-out: Will the ICU attending physician be upset that this took place without him? Will I be in trouble?
Slipping tired feet into well-worn clogs, I grab my white coat and pull my greasy hair into a pony tail. My blue scrubs are ill-fitting; I'm between sizes again.
Night shifts have wreaked havoc on my life. To cope, I eat constantly. At night, I eat to stay awake. By day, if I can't sleep, I eat to fall asleep.
Graham crackers and peanut-butter packet in hand, I find a vacant computer and review the latest on Mr. Matthews, an elderly, comatose and very sick man. Except for the downward trend in his lab findings--more anemia and worsening renal failure--nothing has changed. It's as if Mr. Matthews is stalling as he approaches the inevitable.
The conference room seems more like a utility closet with tissue boxes than a room where serious news is delivered. Peering through the door, I see that Mr. Matthews' family has arranged the fold-up chairs in a circle. Based on the noise level, it's obvious that most of them haven't seen each other in quite some time.
Their animated laughter makes the gathering feel more like a church social than a serious family meeting. The smiling men wear canvas pants and flannel shirts, sleeves rolled up. A round man, motor grease under his cracked nail beds, says something about making it over the pass with the motorhome without needing to put on the chains. The women in the room are cooing over a new baby.
Walking in, I'm greeted by immediate silence. I take no offense: I'm familiar with this part of the drill. The group is sizing me up, waiting for bad news. These people have no medical background. They farm. They raise cattle, sheep and alfalfa, things I haven't got a clue about. They're reading me--my face, my body language--and waiting. The room is frozen. In order to do my best, I have to connect with them on a personal level, and I have to do it quickly.
Pushing my glasses to the top of my head, I pull up a chair and sit down with them.
"I'm Dr. Amy Cowan, the resident taking care of your father," I say.
More silence, more staring eyes. Taking a new tactic, I turn to the young mother next to me.
"What a beautiful baby you have!" I exclaim. It's so off the wall, I'm not even sure I said it.
The room exhales. She smiles.
"Would you like to hold him?" she asks.
"Absolutely!" I say with complete certainty. The first thing all night I know how to handle. I reach for the hand sanitizer, douse my hands and rub the stuff up both arms, just to be safe.
At six weeks, this tiny boy resembles an ancient holy man, wizened by years of sun. Wrapped tightly in his blanket, he blinks and scowls as I reach to cradle him. The family's tension eases, and the room fills instead with the weight of the conversation to come.
Mr. Matthews has been the patriarch for this family for decades. Now he's unable to make decisions for himself. To learn what he would have wanted for his end-of-life care, I need to ask his family. They're the experts about this man. I'm not.
Without an advance directive or named healthy proxy, I have to start from scratch. My scratch is nothing scientific; it's simple, basic and nothing I was taught in medical school.
"What was he like, you know, before all this?" I ask, looking directly at one of the men in flannel.
"You mean, at home on the ranch?" He wants to be sure he gets it right.
"Yeah. What did he like, what really mattered to him, what would he never do?"
The stories start out in snippets. His daughter tells about last spring, when one of the cows tipped over and pinned her dad to the ground. Afterwards, despite being stiff and sore, he was adamant about not seeking medical attention. For days he limped around the ranch, using a stick he'd fashioned into a cane.
His brother-in-law tells of their duck-hunting trips. They often spent whole days behind a blind, storytelling and drinking beer. When the jokes and stories ran out, they enjoyed the silence.
"Grandpa's medicine bottles haven't been opened," the baby's mother says. "He didn't care for doctors. No disrespect."
The stories become lively--even funny, when his practical jokes are remembered. Occasionally a woman in the room wipes away tears. It's becoming clear that this was a fiercely independent man with a contagious sense of humor. Despite the gravity of the subject, at times I laugh too.
The weight of this sleeping baby calms me. I realize that I'm bearing witness to the full circle of this family. In my arms lies their next generation, while nearby machines keep their past alive.
Their stories tell me more about this man than any lab value could. The stories guide me to make a medical recommendation that will honor what matters most to him.
Later that morning, Mr. Matthews dies on his own terms, comfortably, with his family surrounding him.
No one ever regrets coming too soon.
About the author:
Amy Cowan practices as a hospitalist with the VA in Salt Lake City. "Working with internal-medicine residents and taking care of veterans continues to be my greatest joy. I wrote this story as a reminder to myself to be as creative as the situation demands. It's when I connect with patients that my work has the most meaning and I'm the happiest."