DEATH

A majority of my articles focus on a specific medical problem, including the pathophysiology, disease process, signs, symptoms and treatment. This is because I practice evidence-based medicine--which means that what I do on a daily basis is founded on medical literature and current recommended practice guidelines.

Those guidelines are constantly evolving with advances in science. The treatment I may have recommended six months ago, can be different from what I would advise today. Thus, keeping abreast of the science of medical practice is important in providing the best possible care. But, emotion and empathy are just as important. It is my hope that I am able to provide emotional support during a time of crisis that parallels the quality of my medical care.

Recently, I was involved in a case that has had a tremendous emotional impact on me and my staff. In nearly 20 years of practice, I have not experienced such a situation. Let me share some of the details.

An elderly gentleman presented to the emergency department with complaints of jaw, neck, shoulder and chest pain. His pain came on in the middle of the night and was the worst that he had ever experienced. It seemed to wax and wane, so he decided to come in during my morning shift. He was not really interested in giving me a history, but wanted me to treat his pain. Because he admitted that he did not often seek medical care, the fact that this tough, old guy wanted me to treat his pain indicated how severe it was.

This presentation was clearly an emergency and a CT scan of the chest was necessary. We needed to act fast because I was concerned that this was a classic presentation of a dissecting thoracic aortic aneurysm—a life-threatening condition in which a weakened wall of the aorta can bulge or balloon, then rupture and cause internal bleeding. I provided pain relief after my exam and whisked him off to the CT scanner.

In a few minutes, my worst fears were confirmed by a frantic call from the radiologist reading the CT scan. This pleasant gentleman, with a dry sense of humor, had an aneurysm that started in his heart and extended to his kidneys. One kidney was already affected by the growing aneurysm. Blood flow was being impaired and immediate cardiothoracic surgery was necessary. In addition, the CT scan revealed a new lung cancer.

After I presented this case to the patient and his family, he told me that he was a widower who missed his wife. He stated that despite his family, he was very lonely. In addition, he had chronic arthritic pains and back pain--he could no longer do the activities that he loved. The medical information that I provided to him was very grim, and he stated that it was his time. He wanted to be with his wife and felt that he had had a good life. Quality of life was important to him and now his was poor.

I outlined the risks, benefits and alternatives of his conditions. Without surgery, his chance of survival was less than 10 percent. Even with surgery, he had a 40 percent chance of dying. If he did survive, he would face radiation and chemotherapy for his lung cancer. This dear man let me know that he wanted to die with dignity and in comfort. He saw his wife suffer with cancer and he did not want to go through this ordeal.

As a physician I have a duty to preserve life, but I must respect the wishes of my patients. There is nothing wrong with not undertaking extraordinary means to preserve life. This was clearly a terminal situation and I wanted to make my new friend happy and comfortable. He asked for a phone after his family had left and he contacted a funeral home to make his own arrangements. After that was done, he asked to return home to die.

His final request was that I keep him comfortable, as he did not want to experience the extreme pain of his condition. I provided the strongest pain medication available and he left, thanking me for my care and compassion. He died that evening in the company of his family.

A few days later, a nurse told me that as he left, he wanted everyone to know that he could not thank them enough for respecting his wishes, being honest about his condition, and allowing him to die with dignity.

This is what medicine is truly about and I will never forget him.

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