Wednesday, May 20, 2009
He's probably dying right now. He was breathing in the teens--comfortably for the first time in days and the morphine drip had been turned up to 10. They said he was unresponsive but when I went in to hold his hand and say his name and tell him to relax and everything was okay, he opened his eyes. I stood with him for a while, watching out the window, thinking how sad it is to die alone. They only person he had was his housekeeper and he didn't want us to call her. When Julie, the nurse, tried anyway, no one answered. He was breathing with a face mask now. He'd been grumpy since I'd admitted him a week before. At first he had a head bleed from taking too much coumadin (or at least his INR was too high at 9.8) and had bled into an unusual spot in his head that neurology thought might be a metastases from an undiscovered cancer. I went in to visit him even after I'd transferred him to the neurology service. Once day I went in and he was sitting at the side of his bed with his head bent down over his bedside table. I said hello and asked him how he was feeling. He told me to wait a minute. I thought he had questions for his medical team so I told him I was only visiting now and the neurologists were his doctors. "Just wait a minute. We can talk." I felt bad. He'd only wanted company, which is what I wanted to be, but I didn't understand. He didn't really have much to say. I stood there and held his hand for a minute before he shooed me off, "Okay, you can go now. I'm going to meditate."
Ali surprised me with a visit on that first night when I admitted him with the head bleed. He was sitting outside the room after I visited Mr. M. and he'd curtly dismissed me, telling me he wanted to sleep. Mr. M. was grumpy. He wanted to be left alone, "I'm fine!" He softened up a little. He'd been having trouble breathing for at least a month, he told me, but today he had weakness on his face that was new--"heaviness actually." He came in because he was worried he'd had a stroke. When the head bleed showed up on the CT and his INR came back at 9.8, likely from taking too much coumadin, a grilled him about his diet and his activities. He didn't shop. He didn't eat well. That last month he could barely walk around his apartment without getting short of breath. He'd been to the coumadin clinic 1 month before and always on time for the past three years and his INR has always been in the right range--until now.
It wasn't until a couple nights later when Ali and I started talking some how about how many older people who are lonely commit suicide by either taking too many pills or exacerbating their medical conditions on purpose that I wondered if Mr. M. had done that. He insisted to me that he'd taken the right amount, recited his doses to me correctly and everything, "Five on weekday and seven mg on Sundays." He looked irritated and disheartened when I told him I thought it was the medicine that had done this to him. He seemed shocked.
When I first saw him in the ER he didn't even want to talk to me because so many people had already asked him a million questions. I told him I'd wait and we could see him upstairs. The neurosurgeons wanted "neuro checks" every hour all night. Wake up, open your eyes, have a bright light shone in both of them, move your hands and feet. Go back to sleep and repeat every hour. (I remembered my neuro checks every four hours when I was a patient and even that was horrible. Every single hour. There's no way he slept much those first few days he was there.) I asked him if he felt depressed. He did. He lived alone and had no family. Had been married once, but wasn't now and didn't seem to want to talk about it so I dropped the subject. Had no children.
He did fine in the ICU and I transferred him out the next day. I almost sent him to the medicine team, but on second thought I figured it should be neurology to watch over him since his head bleed and his new kepra dosing was his main concern. Though he had so many medical problems that I knew they couldn't handle well that I hesitated. His COPD was "end stage" with an FEV1 of 1.47. His heart failure on his new echocardiogram had progressed to "severe diastolic disease." His atrial fibrillation was uncontrolled since we'd stopped his medicine for it because of his new low blood pressure. His coronary artery disease had necessitated a coronary artery bypass graft a few years before. His legs were almost black from decreased blood flow related to his peripheral vascular disease. His chronic kidney disease had acute kidney injury stacked on top of it since he hadn't been eating or drinking well and since his volume status was a fine balancing act with his heart barely able to pump any more.
On the neurology service, they started him on an antidepressant and got a medicine consult to follow him (unfortunately not one of our most stellar attendings was on consults at that time). They didn't restart his home medications and they gave him more fluid than his heart could handle so a lot of in ended up in his lungs, making it harder and harder for him to breath. He may also have been aspirating some of his food and developed pneumonia in the interim.
He transferred off our service after about 12 hours and out of the ICU the next morning. I had the next day off but was worried about him so followed along as much as I could on the computer from home. After a couple days I didn't hear about him until one of the traveling nurses who worked in the ICU also came to find me since neither the neuro intern nor attending had paged her back for three hours, during which time she'd called a rapid response o him because he was working terribly hard to breath and his PO2 on his blood gas was 45 and he was in afib and tachycardic and hypotensive. She came to find me just as I was having anesthesia intubate another patient in the other step-d0wn unit, "Can you come see Mr. M.? I can't get in touch with his team." He looked terrible when I got there. I ordered a few things and then asked him if he remembered me and how he was feeling. He remembered me, and though his breathing was very labored he said he felt fine, in very short sentences.
I paged the neuro intern again, signing it "ICU resident" and he called back at last. When I told him how sick his patient was he said he'd be there in 10 minutes--and he'd called from an outside line though he was supposed to be in house. My worry for Mr. M. mixed with my irritation about the lack of recognition about how sick and fragile he was. I told him what to do and cleared a bed for Mr. M. in the ICU again (the same bed he'd had before--the one with an ocean view where you could see downtown and the airplanes fly in and out). But the neuro intern didn't say anything about moving him. I called him shortly after and got a little more stern, saying that he at least needed to let his attending know how sick he is and strongly suggesting that he be trasnferred to at least a medicine team and probably back to the ICU (me). "Oh. Okay. Yeah. Thanks. Sure. I'll call him." I'm sure they do a much better job with all the stuff above the neck than I do, but at the very least he needed to know when to ask for help. And though I very rarely make a fuss, I fussed at him quite a bit about needing to respond to pages and recognize when his patients get much worse.
Soon after I got a page saying his attending "would be happy to transfer him to wherever I thought most appropriate." Good thing since I'd all but finished the transfer orders already.
That whole night, I tried not to intubate him. His COPD was so bad I thought he'd never get off the ventilator if I put him on it. He didn't want the BiPAP mask (though he agreed to it by the next morning) so we fiddled around with face masks and nonrebreathers and oximeters and the like. I diuresed all the extra fluid I could off of him with a bumex drip and diuril. I controlled his out of control heart rate with a continuous infusion of a diltiazem, a rate controlling medication. His blood gas didn't get better, but it didn't get worse either. The fellow that night gave him a 50/50 chance of being intubated by morning. We made it through the night, though.
When I went to say bye to him that morning, I told him I had the next day off but would be back on Wednesday (today) and that I wanted to see him without a tube down his throat.
He was already telling the nurses every morning, "I'm going to die today." Of course yesterday he said it more non-chalantly. Today he was more serious.
One of the interns was going to round on him this morning, but I told him I wanted to instead. He looked no better, but also no worse. He still worked hard to breath and that couldn't last forever. We decided to put an arterial line in him on rounds and by the time we got around to doing it, the results were terrible, pH had gone from 7.37 to 7.19. Not good. And while he'd been more of his cantankerous self the day before and even this morning, he was no longer saying he felt fine. "How's your breathing, Raymond?" "Not so good," he gasped.
Neal, the intern, talked to him about wanted a tube to help him breath. He shook his head, "no," no longer able to talk much for lack of breath. "Do you understand that you might die without one?" He nodded. "Open your eyes, Raymond! I need to make sure you understand this." And he repeated the same questions in different phrases. The answers were the same. My eyes welled up as suddenly I flashed into his acidotic mind and wondered how it would feel to have someone ask you if you understood that you probably would die--very soon. And die without anyone except people you'd met seven days ago. Like your life had been a blip on a screen that was about to go out and no one would even remember you. No one, except perhaps your cleaning lady and her daughter, would even know that you were gone. And who knows if they would care.
The day before he'd met with social work and had been very anxious about being able to pay his rent by June 1st or he would lose his apartment. He also worried that if he died his cleaning lady, Rosarita, had only three days to clean out what she wanted from his apartment where he's lived alone for 15 years, before everything else went to the Salvation Army. He'd fretted about it since before he transferred back to the ICU. On the day when the nurse came to tell me he was breathing so badly, she told me he'd made her look in his wallet and get the card for a mortuary that he carried there. And get the card for his house-keeper to tell her to make sure to clean out his apartment within three days of his death.
It was as if his life would just blow away with the ocean breeze, as if he'd rustled around with the leaves for a few days and then...gone. Nothing left. Things he'd known and recognized and used daily given away. Maybe items he's saved or treasured left without stories or context or care, with no one to remember or know.
I wondered what he thought as he drifted off into that morphine-induced haze as I held his hand and stroked his hair and tried to imagine what his life might have been like, or what he'd wanted it to be like. If he'd had regrets. If he'd pictured his end differently. If there was someone he'd love who he wished were there instead of me. He still opened his eyes when I called his name, "Raymond," the muscles above his eyes flickered and his eyelids rolled slowly up and his eyes moved to focus on me briefly, "It's me. Everything is okay. You're doing great. Just relax now." That morning he'd told us he was fine and that he needed a shave and a haircut. It was hard to understand him through the mask and he'd had to repeat the "shave" part a few times and got irritated.
I looked at his salt and pepper stubble under the oxygen mask and wished we could shave him while he still had any connection with this world. Julie rubbed his face with a warm washcloth over his eye lids and his forehead and his hair and his dry lips sucking in numbered breaths. The scar across his chest reminded me of his CABG a few years before and I wondered who had helped him recover from that. Or who had gotten him to his coumadin appointments or to his doctor's appointment with one of my co-residents. I remembered Pop had had a CABG too, and I'd come home to take care of him. My hands were colder than Raymond's, but I knew they wouldn't be for long. I squeezed his hand and rubbed his shoulder and looked at the liquid drip into his veins. His arterial line was oozing and when I moved my hand away there was a puddle of serous fluid in his palm. I was surprised each time I returned and his hands felt so warm.
His heart rate had slowed way down, despite us turning off both rate-controlling medications. His blood pressure was low again. His O2 sat was 92%. I watched his heart monitor flutter around 66-62-60-58-59-58-57. When you don't get enough oxygen and your most recent blood gas shows that your pH is 7.10, your heart doesn't work well. Your body is tired.
I remember now what I said at Pop's service, that he was tired and it was time.
And maybe it is time. I fretted and went back and forth with his intubation with the attending earlier, knowing that I could convince him to get the tube in in throat and that on the ventilator I could fix his blood gas. But I couldn't fix his lung disease, or his heart disease, or his kidney disease, or his loneliness. The most I could do was prolong this inevitable thing that may have taken him even as I have been writing. And he may do to a nursing home or a "rehab" facility which the fellow, who did moonlighting there, said was "a fate worse than death." I knew Raymond was tired, too, and that he felt tired, and sad, and frustrated and alone. I supposed he was ready, "Do you understand that you might die?" Neal yelled at him as we tend to do with those who are very sick. He nodded.
I fought back tears as I held his hand and looked out his window, thinking of my med student's patient who had died a couple years before at the VA and her asking me if I'd been there when he died. I hadn't. The nurses called when he was almost gone, but I didn't want to see the end and he'd been in a coma all day.
All I could do now for Raymond was bear witness to his candle flickering out. I could make him comfotable so his last breaths weren't agonal. I went to the bathroom and came back to say goodbye to him, "Just relax," his eyes flickered again and I placed my other hand over his heart feeling it beat, still warm, in his scared chest, "Everything is okay. I'll see you soon. You're doing great." I squeezed his hand and asked Julie, who was now doing her charting in his room instead of outside where the nurses usually sat to keep his respiratory rate below 30--to keep him comfortable. She said she'd thought he would go faster once we'd started the morphine drip, but she wanted to not let him die alone.
As I waited to talk to her before I left, they moved his 84 year old neighbor out in a body bag. He'd come in the night before after being found on the floor of his apartment covered in flies and feces when the management came in to see if the fire alarm was still working--so dehydrated his tongue was retracted back into his throat. His leg was dead with dry gangrene and by the morning when I came in his arm, too, was cold and pulseless. And while he'd been report-ably able to nod appropriately in the ER, he was no longer waking up at all even though we'd turned off the sedation hours before. I cringe to think that his last days were spent alone on the floor of his apartment like that. I cringe and I cry. I'd tried to find any family or friends of his that morning, but he'd only listed the security guard at the place where he had lived five years ago, a man who remembered him but had only had casual small conversations with him and knew of no family or friends. Every year after that when he'd renewed his lease, his apartment manager had said he'd left that line on the form blank. "No family or emergency contacts listed." Not a single soul to call or care or even know that he's gone. No one to claim the body. No one to know.
Perhaps they have both touched people in their lives who will remember them. Perhaps Raymond was grouchy always and drove people away. Perhaps the other patient, who his landlady called, "a sweet man," did not remember those last horrible days, but some good day. Maybe a day he spent in the woods or at the beach with someone he once loved. Or maybe a day spent alone but with that unreasonable happiness that has no explanation except that it is. Maybe Raymond is glad he is not dying alone. Maybe he's glad to be going. And maybe he's going somewhere more hopeful where he can breath easily and his heart can beat strong again and he can walk on feet that done constantly ache. My fellow said she doesn't know how people can do this job without some sort of belief in a higher power and some place after.
I don't always know what I believe, but as I placed my hand over his heart and said goodbye, I said to myself, "May God bless you and keep you." May he indeed. In a way that mankind has not blessed or kept you. And in a way you have not been able, perhaps to bless and keep yourself.
When Raymond came in that first night, grouchy as ever, I'd asked him what he liked to do and if he had any friends. "No, I don't talk to people much. I'm a thinker. I like to think. I like plays and opera. I'm deep. I never finished more than eighth grade, but I like real conversation. I don't watch that trashy TV. I read books." I pictured him then in his apartment, alone, thinking about ideas he didn't or couldn't express. I wondered how he'd watched opera or if he really had or just wanted to. "I'm deep!" he'd insisted to me, as if he still has something to prove.
But he had no more time to prove anything. Or maybe he did. Maybe that it really was his time to die, and those cards he carried around in his wallet and his worry about his house-keeper cleaning out his apartment said that he was ready. Maybe he proved again to me that sometimes it is okay to go. Maybe even that it is okay to go alone, if that's what you want. Maybe that this grief of his solitude that we have imposed on him is akin to the pity he disdained. Yet, still I believe that holding his hand and a wet washcloth on his face and a stroke of his hair felt good, and felt like someone on this earth cared enough to make it okay for him to go on to the next.
All he'd wanted to eat on his meal tray the day before was the vanilla pudding. Julie said he'd scarfed it down. Today we got him more vanilla pudding. It was all he wanted to eat. That and a milkshake. Two puddings and an Ensure (the closest we could find) sat unfinished on his bedside table.
You see, Raymond, you are not forgotten. Now at least someone will remember that you liked vanilla pudding. And that you liked opera. And that you meditated. And that you liked to think. And that you were tired and ready to move on. I may not know your whole life, except what I imagine, but these things I know. You are not forgotten. Even as I picture you barking, "Forget me! Leave me alone. That's what I want."