- Email: [email protected]
Transitions
REFLECTIONS
Transitions Kristin L. Leight, MS III Harvard University, Boston, Massachusetts When I first heard his name mentioned on rounds, Mr. R. J. Spratt (modified version of patient’s name), I had the very random thought that it sounded like that of a Dickens character. So, when he became my patient, and I saw him for the first time, I was surprised to see that this name suited his bearing. Most notably, Mr. Spratt had an enormously distended asciticfluid–filled abdomen. This, plus his fair complexion, his distinguished nose, and his small stature made him a perfect Dickensonian figure. I could easily imagine him dressed in a waistcoat, twirling a pocketwatch, swashbuckling about, while rubbing his protuberant belly. Only Mr. Spratt’s oversized abdomen was not the result of gluttony or alcoholic overindulgence, as would have been the case with a Dickens figure, he was the victim of a rare disorder called carcinoid tumor. And poor Mr. Spratt was not swaggering about in a jolly way, as I wished him to be, but confined to his bed in a profoundly sick and stuporous state. He was a prisoner in his distorted body. Every time I saw him I thought of a turtle on its back; he could barely move, his stomach was so enormous. Originally Mr. Spratt was not my patient. He had been a “bounce-back” to one of the interns, meaning she had treated him before recently, so he was readmitted to her care, and thus I did not have the opportunity to admit him. However, when one of the patients I had been carrying at the time was discharged, the resident suggested I start following Mr. Spratt, as he was a “good medical student case.” It was so: Mr. Spratt had been found to have carcinoid several years before, when it had metastasized to his liver. He had been treated with chemotherapy that had been discontinued the previous year due to side effects, and for the past few months, he had suffered from chronic ascites due to tumor invasion of his liver. During the course of his hospital stay, he developed spontaneous bacterial peritonitis and eventually hepatorenal syndrome. He also had hepatic encephalopathy, and his asterixis was a favorite physical finding that the residents liked to point out to the students. Poor Mr. Spratt must have started to believe he was a traffic guard, so often was he asked to “stop traffic” in order that we might see his liver flap. There were only about 6 days between the time that I started following Mr. Spratt and his death. For each of those mornings, Correspondence: Inquiries to Kristin L. Leight, MS III, Francis Weld Peabody Society, Harvard Medical School, 260 Longwood Avenue, Boston, MA 02115; e-mail: [email protected]
174
when I would pre-round on him, I would ask his name, and he would say in a ceremonious, albeit barely understandable, way “R---- F---- Spratt, Jr.” He never forgot the “junior,” not even on the last day. But he often did forget the year and the place where he was staying. I discovered from his wife that he would study for these sessions, repeatedly asking her the name of the hospital and the date so that he could answer correctly, which I found poignantly sad. He was probably accustomed to giving the correct answer most of his life. It was easy to tell that he was an intelligent and dignified man, and it was heart-breaking to see him confined as he was— by diapers, by restraints (he fell several times), and by his own failing body and dulled senses. The last few days before his end, when he could barely answer my questions, I would, after I examined him, stand with my hand resting on his abdomen, watch his laborious breathing, and try to imagine him as he was in his pre-hospital life. I had surprisingly clear, almost movie-like images of him: Mr. Spratt playing with grandchildren, presiding over the turkey at Thanksgiving, grilling in the backyard. And this made me feel strangely connected to him, despite his silence and mine. It is said that the comatose are still aware of who and what is around them, and I hoped that Mr. Spratt, in his stuporous, pained, and nearly comatose state, could detect a presence that wished him well. When I first started following Mr. Spratt, the attending asked me to give a presentation on his history and hospital course and to try to explain what was going on with him medically. I had put it off because his case was so complex; it had required hours of poring over his medical records, laboratories, and studies, not to mention the literature on carcinoid, SBP, hepatic encephalopathy, and ascites. When I finally met with the attending one Friday afternoon, I was apprehensive about my presentation and did not feel as though I had gotten the big picture on Mr. Spratt. I had not, but luckily based on the information I gave him, the attending was able to see things more clearly. He was able to conclude that both Mr. Spratt’s liver and kidney function were significantly declining and that his prognosis was poor, much worse than the attending originally believed. Strangely and serendipitously, 10 minutes after our meeting, Mr. Spratt had a hypotensive episode and the covering intern, who did not know the patient, called our attending to the floor. I happened to be wandering by when it occurred and was a witness to what followed. After the attending confirmed that
CURRENT SURGERY • © 2003 by the Association of Program Directors in Surgery Published by Elsevier Science Inc.
0149-7944/03/$30.00 doi:10.1016/S0149-7944(02)00778-X
Mr. Spratt was stable, he pulled the family aside to talk. The day before this, the intern had broached the subject of code status with the family, who had elected to keep him at full code. One of the daughters, who tended to be feisty at times, reminded the attending of this sharply when he brought it up again. “We already discussed this yesterday, we don’t need to go over it again.” The attending answered gently and nondefensively, “I realize that, and I don’t want to cause you any further pain, but I think it is worth discussing again. I just reviewed Mr. Spratt’s case extensively, and I have to tell you that I think he is declining quickly. His kidneys and liver are failing, and it is only a matter of time now. If you choose to keep him at full code, he will be resuscitated when he dies. And what you need to realize is that this will not prolong his life significantly.” What ensued was a calm and honest discussion, the result of which was that the family decided to make him DNR/DNI and asked that he receive comfort measures only. Those 10 minutes of discussion radically transformed our treatment plan; the goal was no longer to try to improve his condition, but rather to stabilize him so that he could go home to die. More importantly, it telescoped the situation for the family. Not only was he going to die, but soon. It seemed to me, although I could not know for sure, that no one had given them this message before or laid it out so clearly. It is a very strange experience to be present at the most significant moments of others’ lives, when you have no prior intimate connection to them. It is equally disconcerting to be in the midst of one of these life-changing points in time and to realize that the world is proceeding as usual around you. There is a wonderful Auden poem, “Musee des Beaux Arts,” that describes this incongruity: “About suffering they were never wrong,/The Old Masters: how well they understood/Its human position; how it takes place/While someone else is eating or opening a window or just walking dully/along;” and, my favorite line, while “the dogs go on with their doggy life.” I was acutely aware of this uneasy coexistence of the profound, the tragedy occurring in their lives, and the mundane, what was going on in the hospital around them, during that conversation, and again, when Mr. Spratt died 2 days later. It was a Sunday afternoon, and I had been writing a summary of his case, an “off-service note” for the intern caring for Mr. Spratt, who was leaving the following day. She and I had also spent a good deal of time discussing how to present him to the new intern and resident and how to manage his discharge home. Earlier that day, the family had asked her if he could go home that evening. The intern hesitated about it, and said she was not sure he was stable enough. I beseeched her, and my motivation was not entirely
CURRENT SURGERY • Volume 60/Number 2 • March/April 2003
selfless. I wanted him to go home quickly so he could die surrounded by his family, but to be honest, I was also scared to be the only person left on the team who knew anything about him, especially when he was on death’s door. We made some calls to see about getting him the proper hospice care at home that night, but it turned out to be impossible. Frustrated, I went to check on him, only to find that all his family was in the room. Not wanting to intrude, I ducked across the hall to see my new patient. And during that 15-minute interval, Mr. Spratt departed this world. I walked out of my new patient’s room to see the intern emerge from his. I asked what was going on, if I could do anything. “You know he died, don’t you?” she said abruptly. I did not. I grabbed her arm and repeated it incredulously, “He died? Oh my God, Oh my God.” I do not know why in that moment I had such trouble accepting it as fact. She kept walking toward the end of the hall, where the family was clustered. I followed, but she motioned me to stay back. I felt frustrated, and conflicted. I had a strong urge to go with her, to offer what little consolation I could, although I was at the same time scared to go. As I waited for her, I remembered back to the time when my grandfather died of a hemorrhagic stroke at Duke Hospital. I recalled the nurse who brought us drinks when we were saying goodbye to him; people still get thirsty at a deathbed. I remembered the kind person who gave us her cellular phone—for some reason, we could not use the emergency room phone to dial long distance—so that my grandfather could say his final words to his son. I recalled the young neurology resident, who told us, so kindly and so regretfully, the news that he was going to die imminently. All of these people and these moments mattered. Although these people did not fully share our grief, their acknowledgment of it, their witnessing it, and their concern for us, the survivors, was truly meaningful. I wanted to honor the grief of the Spratt family. I lingered in the hall until his wife and two daughters came out of their talk with the intern, and I stammered out that I was sorry for their loss, that I had enjoyed knowing him, and that he was a wonderful man. They nodded tearfully and made their way to his room. As I rode home that afternoon, the sun was shining brightly, glinting off Jamaica Pond. How precious, brief, and transient is life. My feelings about Mr. Spratt’s death were a mixture of sadness and relief. I thought back to that morning when he had a moment of lucidity, roused from his alternate reality long enough to tell the attending that he wanted his restraints removed “now, N-O-W, now doctor, and I mean it. I want to be free.” Released from the shackles of his body, he finally was.
175
Transitions Kristin L. Leight, MS III Harvard University, Boston, Massachusetts When I first heard his name mentioned on rounds, Mr. R. J. Spratt (modified version of patient’s name), I had the very random thought that it sounded like that of a Dickens character. So, when he became my patient, and I saw him for the first time, I was surprised to see that this name suited his bearing. Most notably, Mr. Spratt had an enormously distended asciticfluid–filled abdomen. This, plus his fair complexion, his distinguished nose, and his small stature made him a perfect Dickensonian figure. I could easily imagine him dressed in a waistcoat, twirling a pocketwatch, swashbuckling about, while rubbing his protuberant belly. Only Mr. Spratt’s oversized abdomen was not the result of gluttony or alcoholic overindulgence, as would have been the case with a Dickens figure, he was the victim of a rare disorder called carcinoid tumor. And poor Mr. Spratt was not swaggering about in a jolly way, as I wished him to be, but confined to his bed in a profoundly sick and stuporous state. He was a prisoner in his distorted body. Every time I saw him I thought of a turtle on its back; he could barely move, his stomach was so enormous. Originally Mr. Spratt was not my patient. He had been a “bounce-back” to one of the interns, meaning she had treated him before recently, so he was readmitted to her care, and thus I did not have the opportunity to admit him. However, when one of the patients I had been carrying at the time was discharged, the resident suggested I start following Mr. Spratt, as he was a “good medical student case.” It was so: Mr. Spratt had been found to have carcinoid several years before, when it had metastasized to his liver. He had been treated with chemotherapy that had been discontinued the previous year due to side effects, and for the past few months, he had suffered from chronic ascites due to tumor invasion of his liver. During the course of his hospital stay, he developed spontaneous bacterial peritonitis and eventually hepatorenal syndrome. He also had hepatic encephalopathy, and his asterixis was a favorite physical finding that the residents liked to point out to the students. Poor Mr. Spratt must have started to believe he was a traffic guard, so often was he asked to “stop traffic” in order that we might see his liver flap. There were only about 6 days between the time that I started following Mr. Spratt and his death. For each of those mornings, Correspondence: Inquiries to Kristin L. Leight, MS III, Francis Weld Peabody Society, Harvard Medical School, 260 Longwood Avenue, Boston, MA 02115; e-mail: [email protected]
174
when I would pre-round on him, I would ask his name, and he would say in a ceremonious, albeit barely understandable, way “R---- F---- Spratt, Jr.” He never forgot the “junior,” not even on the last day. But he often did forget the year and the place where he was staying. I discovered from his wife that he would study for these sessions, repeatedly asking her the name of the hospital and the date so that he could answer correctly, which I found poignantly sad. He was probably accustomed to giving the correct answer most of his life. It was easy to tell that he was an intelligent and dignified man, and it was heart-breaking to see him confined as he was— by diapers, by restraints (he fell several times), and by his own failing body and dulled senses. The last few days before his end, when he could barely answer my questions, I would, after I examined him, stand with my hand resting on his abdomen, watch his laborious breathing, and try to imagine him as he was in his pre-hospital life. I had surprisingly clear, almost movie-like images of him: Mr. Spratt playing with grandchildren, presiding over the turkey at Thanksgiving, grilling in the backyard. And this made me feel strangely connected to him, despite his silence and mine. It is said that the comatose are still aware of who and what is around them, and I hoped that Mr. Spratt, in his stuporous, pained, and nearly comatose state, could detect a presence that wished him well. When I first started following Mr. Spratt, the attending asked me to give a presentation on his history and hospital course and to try to explain what was going on with him medically. I had put it off because his case was so complex; it had required hours of poring over his medical records, laboratories, and studies, not to mention the literature on carcinoid, SBP, hepatic encephalopathy, and ascites. When I finally met with the attending one Friday afternoon, I was apprehensive about my presentation and did not feel as though I had gotten the big picture on Mr. Spratt. I had not, but luckily based on the information I gave him, the attending was able to see things more clearly. He was able to conclude that both Mr. Spratt’s liver and kidney function were significantly declining and that his prognosis was poor, much worse than the attending originally believed. Strangely and serendipitously, 10 minutes after our meeting, Mr. Spratt had a hypotensive episode and the covering intern, who did not know the patient, called our attending to the floor. I happened to be wandering by when it occurred and was a witness to what followed. After the attending confirmed that
CURRENT SURGERY • © 2003 by the Association of Program Directors in Surgery Published by Elsevier Science Inc.
0149-7944/03/$30.00 doi:10.1016/S0149-7944(02)00778-X
Mr. Spratt was stable, he pulled the family aside to talk. The day before this, the intern had broached the subject of code status with the family, who had elected to keep him at full code. One of the daughters, who tended to be feisty at times, reminded the attending of this sharply when he brought it up again. “We already discussed this yesterday, we don’t need to go over it again.” The attending answered gently and nondefensively, “I realize that, and I don’t want to cause you any further pain, but I think it is worth discussing again. I just reviewed Mr. Spratt’s case extensively, and I have to tell you that I think he is declining quickly. His kidneys and liver are failing, and it is only a matter of time now. If you choose to keep him at full code, he will be resuscitated when he dies. And what you need to realize is that this will not prolong his life significantly.” What ensued was a calm and honest discussion, the result of which was that the family decided to make him DNR/DNI and asked that he receive comfort measures only. Those 10 minutes of discussion radically transformed our treatment plan; the goal was no longer to try to improve his condition, but rather to stabilize him so that he could go home to die. More importantly, it telescoped the situation for the family. Not only was he going to die, but soon. It seemed to me, although I could not know for sure, that no one had given them this message before or laid it out so clearly. It is a very strange experience to be present at the most significant moments of others’ lives, when you have no prior intimate connection to them. It is equally disconcerting to be in the midst of one of these life-changing points in time and to realize that the world is proceeding as usual around you. There is a wonderful Auden poem, “Musee des Beaux Arts,” that describes this incongruity: “About suffering they were never wrong,/The Old Masters: how well they understood/Its human position; how it takes place/While someone else is eating or opening a window or just walking dully/along;” and, my favorite line, while “the dogs go on with their doggy life.” I was acutely aware of this uneasy coexistence of the profound, the tragedy occurring in their lives, and the mundane, what was going on in the hospital around them, during that conversation, and again, when Mr. Spratt died 2 days later. It was a Sunday afternoon, and I had been writing a summary of his case, an “off-service note” for the intern caring for Mr. Spratt, who was leaving the following day. She and I had also spent a good deal of time discussing how to present him to the new intern and resident and how to manage his discharge home. Earlier that day, the family had asked her if he could go home that evening. The intern hesitated about it, and said she was not sure he was stable enough. I beseeched her, and my motivation was not entirely
CURRENT SURGERY • Volume 60/Number 2 • March/April 2003
selfless. I wanted him to go home quickly so he could die surrounded by his family, but to be honest, I was also scared to be the only person left on the team who knew anything about him, especially when he was on death’s door. We made some calls to see about getting him the proper hospice care at home that night, but it turned out to be impossible. Frustrated, I went to check on him, only to find that all his family was in the room. Not wanting to intrude, I ducked across the hall to see my new patient. And during that 15-minute interval, Mr. Spratt departed this world. I walked out of my new patient’s room to see the intern emerge from his. I asked what was going on, if I could do anything. “You know he died, don’t you?” she said abruptly. I did not. I grabbed her arm and repeated it incredulously, “He died? Oh my God, Oh my God.” I do not know why in that moment I had such trouble accepting it as fact. She kept walking toward the end of the hall, where the family was clustered. I followed, but she motioned me to stay back. I felt frustrated, and conflicted. I had a strong urge to go with her, to offer what little consolation I could, although I was at the same time scared to go. As I waited for her, I remembered back to the time when my grandfather died of a hemorrhagic stroke at Duke Hospital. I recalled the nurse who brought us drinks when we were saying goodbye to him; people still get thirsty at a deathbed. I remembered the kind person who gave us her cellular phone—for some reason, we could not use the emergency room phone to dial long distance—so that my grandfather could say his final words to his son. I recalled the young neurology resident, who told us, so kindly and so regretfully, the news that he was going to die imminently. All of these people and these moments mattered. Although these people did not fully share our grief, their acknowledgment of it, their witnessing it, and their concern for us, the survivors, was truly meaningful. I wanted to honor the grief of the Spratt family. I lingered in the hall until his wife and two daughters came out of their talk with the intern, and I stammered out that I was sorry for their loss, that I had enjoyed knowing him, and that he was a wonderful man. They nodded tearfully and made their way to his room. As I rode home that afternoon, the sun was shining brightly, glinting off Jamaica Pond. How precious, brief, and transient is life. My feelings about Mr. Spratt’s death were a mixture of sadness and relief. I thought back to that morning when he had a moment of lucidity, roused from his alternate reality long enough to tell the attending that he wanted his restraints removed “now, N-O-W, now doctor, and I mean it. I want to be free.” Released from the shackles of his body, he finally was.
175