A Time to Die?

I’ve always liked this hospital. It’s small, just two stories, with natural light flooding through the rain-cleansed windows.

My patient Ruby is on the ground-level medical ward. The ward’s Maori name, Muiriwai, means “confluent point of two streams.” Each ward has a Maori name and four beds. There are no private rooms in this public hospital.

Ruby is lucky to have a bed near the window. Her right foot’s worsening gangrene might be why she’s received this nicely ventilated spot. As I stand at the foot of her bed, she’s asleep. It’s only 7:00 am.

My eyes smart as I unwrap the foot’s dressing until I reach hard, iodine-soaked gauze. This therapy is unusual, but I’m doing whatever I can to decrease the bacterial count in the rotting foot. Even so, its dead-rat odor makes me step back.

“Good morning,” I whisper loudly.

She opens her eyes, momentarily blank. She’s a beautiful sixty-year-old Samoan woman. Her teeth are in a bedside jar, but she exudes warmth.

“Doctor, you’re here,” she says, groping for her eyeglasses.

“Good morning,” I repeat. “I’m sorry for waking you. I just wanted to see your foot.”

“You are the only one I want to see,” she says.

I feel good and bad about this. Ruby has been under my care before. Three years ago, she had gangrene of the left foot, due to diabetes and poor blood flow, but with revascularization and aggressive wound care, we got the foot healed, albeit short of two toes.

She was ulcer-free for two years. Then, last month, she came to our clinic: She’d suffered a right-heel injury, and her family doctor watched it for two weeks before sending her to us. By then, the ulcer was the size of a silver dollar. Still, I felt optimistic as I referred her to the vascular service.

The vascular service is located not at my hospital but at a major acute hospital in another part of Auckland. Initial consultations can be by email or phone, using photos, rather than in person. Based on a photo of her blackened heel, Ruby was put on a wait list; it was three weeks before she was actually seen by the vascular surgeons at their clinic.

I found their report confusing: “We discharged her, since she refused an amputation.” There was no workup—no consideration of other surgical options.

So Ruby is back with us again, only now with a raging foot infection.

“How are you?” she says. “I’m sorry you have to come so early to see me.”

She grabs a hairbrush, drags it through her thinning black hair, then drops it with a sigh.

“What can I do?” she says.

“Ruby,” I say. “You are dying because of your foot.”

“But there must be something that can be done other than cutting my leg off!” She sits up hopefully.

“Ruby, if you don’t do anything, you will die from infection,” I say evenly. “I don’t want you to die that way.”

She pulls off her glasses and looks right at me. “You tell me what to do.”

“You have to have an amputation,” I say. “It’s not what I want you to have, but at this point, you have no other option.”

I explain why her right knee and lower leg need to be removed. She seems unconcerned. She just wants to go home, and if losing her leg is the way home, she’s agreeable.

“When can we do it?” she asks.

But now it’s the vascular surgeon who opposes the procedure. He emails me to stop Ruby’s antibiotics.

“We have documented well our consultation and her refusal of amputation. There is no treatment other than pain meds. That, in my mind, means no antibiotics. Sepsis is the time to die.”

Even her internist agrees, saying, “Compassion has its limits, Jeff. No good deed goes unpunished around here, remember that.”

Never in my thirty-six years in the high-risk foot service have I felt such emotional upheaval. I put on a brave face–doctors are supposed to show detached concern–but Ruby’s case touches me deeply. I want to help her, while those who could help her seemingly want her to die. I feel like I’m failing her.

I ask Ruby’s internist to speak to the vascular surgeon. The response: “She must have delirium from sepsis, so we cannot get informed consent. Continue end-of-life care.”

I document Ruby’s orientation to person, place and time.

“She is exhibiting normal cognitive function,” I note. I feel that she’s being ignored–that she needs an advocate.

I also worry about my sanity. Whenever I discuss Ruby with colleagues, I cry, sobbing deeply in front of them. I need something to help me focus—to help me feel there’s hope.

I remember the prayer beads given to me by a Turkish friend. I’ve sometimes used them in Friday prayers, but not in a long while.

Now, every morning, I put them in my chest pocket. Whenever I feel depressed, as if I’m working in the depths of hell, I pull them out and count off my prayers. In Islam we often recite one particular excerpt from the Quran, over and over.

In the name of Allah, the most compassionate, the most merciful, I say in my mind, and feel the mercy of God in my heart. It’s a mindfulness exercise, but also a spiritual one.

After two weeks, perhaps because they’ve read my notes on Ruby’s mental status, the vascular surgeons suddenly show interest.

“If she survives another five days,” they say, “we’ll transfer her to our ward.”

They move her there, then decide that anesthesia would be dangerous for her heart. Anesthesia proposes a spinal anesthetic.

Ruby finally has the above-knee amputation and is discharged to our hospital for rehabilitation. I go to see her.

“Jeffrey, how have you been?” she says, using two thin fists to push herself up in the bed. “I’m sorry, I was at that other hospital so long, I couldn’t see how you are. And the family?” Her eyes search mine.

I fight back tears. This woman was near death, and she worries about how I am.

She has the window bed again. Rain mists the air: Cyclone Gabrielle is coming. I ask Ruby about her home. Does she worry about flooding?

“I’m not worried; my husband will watch over everything,” she says, adding, “That poor man. He must feel awful that I’m in the hospital for so long.”

She lifts her amputation stump up and down, left and right, and laughs.

“See that? I still feel like my leg is there, but no pain.” Then her smile flattens to a grimace.

“Can you check my other foot? They say there’s a problem.”

She watches my hands as I remove her sock. On it, I see blood and pus. My heart skips a beat—or two.

On her left heel is a pressure sore from her stay on the vascular ward.

I want to call them up and say: “You look down your noses at everyone. You told this poor woman to die. But you can’t even keep her from getting a pressure sore in your ward!”

I don’t, of course. I clean the sore and dress it.

“You have a wound,” I say. “But we’ll fix it.”

She smiles.

“I trust you,” she says, leaning back and closing her eyes.

I peel off my gloves and wash my hands in the basin between the two large picture windows. I look at her, asleep now. My right hand reaches into my chest pocket.

I count off my prayer beads, reciting a prayer in my heart.