How Many Times Do I Have to Tell You?

*BEEP BEEP BEEP*

Cursing the shrill blast of my pager, I quickly pushed the button to silence the antiquated device and read the illuminated message.

“Please come to room 521, patient would like to talk about curative treatment.”

Unexpectedly, a surge of frustration overpowered me.  I was just in that room 20 minutes ago.  Calling back the nurse, I shoved down the urge to hulk out.  Obviously, he didn’t know I had already seen the patient… this was clearly a miscommunication.

“Hey, it’s Dr. M.  I was just in 521 – did you mean to send me this message before I saw Y?”

“Uh… no, I was just in there and Y asked if you could come back.”

“And he wants to talk about curative treatment?  As in reversing comfort care and hospice?”

“… yes.”

Taking in a deep breath, I could feel the simmer turn into a roiling boil.

Don’t shoot the messenger, M.  It’s not his fault you’re always angry.  And it’s not his fault Y doesn’t understand that there’s no cure.

My mind drifted to the conversation I’d hoped was the last one I’d have with Y.

---

“Why is my voice so weak?”

Catching myself pursing my lips, I converted my facial expression into a small, hopefully reassuring smile.

“It’s because you’re having a hard time breathing, so there’s not enough air going through your voice box.”

“Oh.

…

How do I make that better?”

Looking over at Y, again I caught myself almost giving myself away.

Wiry arms sprawled out to the sides of the hospital bed threatening to swallow him whole, he barely had enough energy to keep his head upright to look at me.  With every breath, his entire chest heaved upward in an attempt to force what little air he could inward.  The chest tube exiting the left side of his body bubbled randomly with his breaths, a reminder of our prior attempts to keep death at bay. 

Those days were behind us though.

You don’t make this better.  There is no getting better.  But every morning you find a different way to ask me this same question, and every morning I have to remind you that you chose to die this way.

Catching his cloudy eyes watching me, I held in the sigh that so desperately wanted to get out.  This was not the time to air my frustration.

“Y… when you decided to go on hospice, we shifted our focus to keeping you comfortable because you no longer wanted to do any more treatments or procedures to address your breathing issues.  If we try to help you get stronger, you would have to participate in those therapies again.  Is this something you want to do?”

Shutting his eyes tight, Y shook his head, lifted his frail hand and waved me off.

“We’re done here.  You can leave now.”

---

Fast forward 20 minutes and he wanted to rehash this discussion after he dismissed me with a flap of his hand? 

Returning to my conversation with Y’s nurse, I barely screened out the irritation in my voice.

“There is no curative treatment for Y, unfortunately, which is what I just told him.  I can come back and discuss this again with him, but right now I have other patients I need to see.”

“So when can I tell him you’re coming?”

Well, I was actually hoping he was going to die today and avoid this conversation again altogether, but no such luck.

Shaking my head at myself, I closed my eyes and flatly stated,

“Some time this morning.”

Taking special care to put down the phone as gently as possible to cover up the fact that I actually wanted to throw it against the wall and watch it explode, I felt my self-control start to slip away.  

What the hell is wrong with you, M?  Keep. Your shit. Together.

But my usual pep talk was coming up empty as the weight of the last 4 difficult months had finally exhausted the fight left in me.  Running on the fumes of my compassion, all I had left was fury.  Except it wasn’t going to be spectacular like the Hulk raging out to save the day.  No, it was more like baby Yoda squinting its way into force choking an ally.  Misguided and entirely counterproductive.

At least you’d be adorable while doing it!  

Smirking, I sat back in my broken office chair and punched #babyyodamemes into Instagram to distract my inner dialogue. 

Desperate times call for desperate measures.

---

Stepping back into 521, deep heaving breaths once again greeted me.  Mouth agape, gravity pulling the flesh from his gaunt cheeks – Y was a corpse who was still breathing.

Just walk out, M.  No reason to rehash this right now.  He’s sleeping.

But I’d just walked from the other side of the hospital to have this conversation, and I’d be damned if I had to come back later.  Placing my hand on his shoulder, I softly called his name.

“Y?  It’s Dr. M.”

With a startle, he woke up.

“Ah, yes.  I fell asleep waiting for you!  It’s about time you came!  Now, I want to talk to you about getting better.”

Nodding my head, the words I’d been mulling over for the last 2 hours finally started to take shape.  How many different ways do you have to tell someone he’s dying before it takes hold?  How many times do you have to repeat yourself before the reality of the situation settles in?

“Y… I want to make sure we’re on the same page here.  You have severe COPD AND you have metastatic lung cancer that has spread everywhere.  On top of that, you blew a hole in your lung and developed a pneumothorax.  Now you have this chest tube that if it became dislodged, you would die very quickly.

I understand you want to get better and stronger.  But there are limits to what your body can withstand at this point.  The things we could do for you might buy you some time, but not much, and that time would be painful for you.  So we need to have a discussion about what ‘better’ means to you, because I think we’re thinking of two very different things.”

As I watched his face, I could feel the weight of my words crushing him.  Every hope held on to the last 2 hours, every thought of a future beyond the walls of the hospital, every anticipation of returning to his own home — smashed.  

Saying this variation of the same monologue for the 4th time didn’t ease the pain, for either him or me.  Saying it for the 4th time only heightened my anger – at his situation, at him for making me lay it all out for him again, at me for allowing this to rattle my inner peace. 

But perhaps this was the first time he was really hearing it.  Perhaps this might be the last time.  

Squeezing his eyes shut, I spied a tear creep out of the deep recesses of his face.  Maybe this was the sign of acceptance I had been waiting for.  Maybe this could finally all be over.

“Y, do you want to talk about this some more?  Or do you need some space?”

Lifting his frail hand, I awaited his dismissal.  Unexpectedly, however, he reached out and found my hand.  

His icy grip shocked me, forcing a glance down to our locked hands.  Blue fingertips with the tell tale signs of clubbing squeezed my fingers to a pale colour matching his.  The bitter cold sucked the little warmth I had in my frigid hands, along with the anger keeping me upright.

Had he truly not understood his situation?  

Or was this his attempt to not die alone?

Looking up at Y’s murky eyes, I recognized the familiar terror intermixed with sadness – the face of someone accepting their fate.  

And in a blink, it was gone, along with the death grip he’d held on me.

“Go on, now.  Get on out of here.”

With a wave of his hand, he dismissed me.

This I recognized too – the withdrawal after being seen.  The anger from having your vulnerability exposed.  The regret of having your need to connect override your usual stoic baseline, your shield against the world.

It was all too familiar.

---

Catching me step out of the room, I locked eyes with Y’s nurse.  He looked younger than I anticipated, his newness given away by his brand spanking new fitted Figs scrubs with the creases still starched in.

 “Dr. M?”

“Hi.. was it you I was talking to about 521?”

“Yeah… how did it go in there?”

“Fine.  We’re keeping him on hospice.  I’ve been taking care of him for the last 3 days, and this is your first day with him, right?

“Yes.”

“Ok… well, just to give you some context, he’s asked every day about how he’s going to get better and get off hospice.  I don’t know how how much he’s retaining of what I’m telling him because by the looks of how blue he is, his oxygen levels are probably in the 70s or 80s.  So if he asks you to contact me again, just let him sleep it off.  

Nobody likes to be told multiple times a day that they’re dying, and I only have it in me to tell him once a day.”

The callousness of my tone took him aback.  Clearly I was not the person he’d previously sized up.  A pang of regret came and went as I realized I was only adding to the perception that doctors don’t care.

There’s a reason “heart of a doctor” isn’t a thing, M.  Nurses have that one down pat.

For a second I wanted to take it back.  Try to prove to this nurse that I did care.  To convince him my brash attitude was the only shield I had left to keep me moving on to my other patients, instead of parking myself next to Y’s bed so he didn’t die alone.  To acknowledge that this was a maladaptive coping mechanism and I used to do better.  

I used to be better.

But I didn’t.

With one squeeze of my hand, Y sucked everything out of me.  

No more anger, no more compassion.

Just damage control to prevent another text page from interrupting my work flow.

Setting expectations for this nurse so he understood that me flying in at a dying patient’s beck and call when there were other patients who could actually be “saved” was not high yield.

This is still doing my job, yes?

And my job isn’t to protect him from the reality of what we do – that ship sailed a long time ago.

Turning to walk away, I gave him my reassuring half-smile as I presented him a reconciliatory gift he didn’t yet know he wanted to take.

“Don’t forget about that morphine, ok?”

And with that, I claimed full responsibility of accelerating Y to the finish line.

Because there are worse ways to die.  

And lingering on when your time has passed is one of them.

.

.

.

***

A little different announcement this week – I am terrified but happy to announce that I’m a panelist at the White Coat Investor Conference in Las Vegas from 3/11-3/14! 

If you happen to be attending, please introduce yourself!

I’ll be the one fan-girling (at THE White Coat Investor, Physician on FIRE, Crispy Doc, The Physician Philosopher, Practice Balance and many others) while also wondering WTF I’m doing here.

See you soon!