I was at the end of a long shift. I had already seen too many patients to have any common sense left and it felt as though there were no remaining neurons firing in any agreeable pattern in my brain. And here came my last patient. I peeked into her room before I showed my own face. She was 78 years old with long gray curls piled way atop her head. Her chest seemingly rose and fell too rapidly for comfort. The sounds of bubbles in her airway were audible even outside of the room.
“Uh oh,” I thought…fate has saved the toughest patient for last. Tough because at first glance I could already tell that I would need to have an end-of-life planning conversation with this little lady. She was already triggering my mental screening tool: Would I be surprised if this patient died within the next year?
The answer was a resounding “no.”
I pulled back the curtain.
“Hi Toots!” She called out to greet me as I made my way into her room. (This was a first…and I liked it!)
This spunky little lady was in the ER for shortness of breath. Again.
As we talked it became clear that she had entered her end-of-life pathway. The last six months she had multiple hospitalizations for pneumonia. She now only routinely walked to the restroom or to the dinner table. She was beginning sleep a lot and there was about 20 lbs. weight-loss.
Despite my fatigue it was my duty to have “the conversation” with this patient and her husband, regardless of the physical and mental energy costs to myself.
So I took a deep, tired, ragged breath and started my usual condensed ED-goals of care conversation:
“Do you have a living will?”
Her husband quickly responded, “What’s a living will?”
Secretly, in the recesses of my imagination, I slapped my forehead, yelled out “Oh brother!” and rolled my eyes. As I sat motionless, fake-smiling at the gentleman, I hoped that none of my true sentiments had shone through in my facial expressions or demeanor.
Before I could continue my spiel with this fake-smiling expression plastered on my face the husband asked, “Does that mean that we ask about her wishes?”
Suddenly I felt as refreshed as after a good nights sleep! “Why yes!” I gushed to
him, my fake-smile now genuine and deep.
“Well, let’s just ask her then,” he said turning to her as my smile turned to an expression of near-astonishment. This had never happened before.
“Honey,” he leaned over her bed rail, “This nice doctor wants to know your wishes like whether or not you want life support and things like that.” He looked toward me as he spoke to her searching my face for confirmation.
Boy, did he get it! I was shaking my head vigorously, “YES!”
“Well, I don’t want all of that. You see, I only want to die once.” She said impishly.
We all burst into laughter.
She apparently took this as her cue. So, she continued, “I mean who in their right mind would want to die twice? Right?”
(She began to remind me of Joan Rivers on stage.)
She kept going…”Why break my ribs just so I can come back to do it all over again? And who came up with that plan anyway, doctor ?!?”
#LOL #ROFL were understatements!
Observing my uncontrolled laughter she said, “At least you’ve got a sense of humor kid. But let’s get on with this admission, I’m hungry….”
So, we did.
Lesson 1- Things are not always as they first appear. Sometimes we are pleasantly surprised.
Lesson 2- Fatigue is no excuse for skipping what could be the most important healthcare planning conversation in a patient’s whole life.
Lesson 3- Always find a reason to smile or laugh with your patients (even if it’s a choice )