Death closes all: but something ere the end, Some work of noble note, may yet be done, Not unbecoming men that strove with gods.Alfred, Lord Tennyson
I met her as an “unassigned patient.” These are the people that are brought, or bring themselves into, the emergency department and who have no primary care doctor. The hospital keeps a “call schedule” that assigns these patients to a primary care doctor on staff on a rotating basis. She became ill on my day.
She was in her late sixties. She had spent most of her life as a teacher. Her husband worked at a local manufacturing plant. They never had children. He had died a decade earlier. She had no siblings, and all of her (few) friends had either died or moved away. She was alone.
About once a year I ran into this situation. Nice, educated human beings who feel very comfortable with a limited social circle. I always wonder about the why. Being as nosy as I am I ask, and I have never been able to get an answer that fits all. They just like it that way; they had fun with their husbands/ wives/ few friends and they saw no need to change a good thing. They were by no means loners who were socially inept.
She fit that pattern. She was a bright, very polite, well-read woman. After her husband died she had settled into a pattern of isolation that allowed her plenty of time to read and to listen to music. I did not think that she was depressed, or bored, or even lonely. Over the few weeks prior to her ER visit she had noticed decreased appetite and a bloated feeling around her upper abdomen. Her stools lost some of their color. She thought that she looked pale. On the evening that she could not even hold a tablespoon of soup down without becoming nauseated, she drove herself to the hospital.
It only took one look to realize that she was in deep trouble. What she interpreted as pallor was deep jaundice. She was the color of an orange. She showed signs of muscle wasting, due to malnutrition. She had what I thought was a mass in her abdomen. Further tests showed a cancer in her pancreas that had spread to the liver and was cutting off the flow of bile. Her prognosis was dismal.
I sat down on her hospital bed to explain our findings. She was a model of resignation and equanimity. It was clear to me that she had known for years that this moment had to come sooner or later (don’t we all, but most of us are not as keenly aware of this reality). She calmly accepted the grim outlook and gently but firmly told me that there would be no more treatment.
In those days there was no hospice care. I had noticed that she had spells of decreased alertness, so sending her home was not going to be an option. I alerted the hospital social worker, and I knew of a nurse whose church members liked to help out people in this situation. She had enough financial resources to pay for whatever was not covered under Medicare.
She felt uncomfortable with the idea of going to a nursing home. I assured her that I knew of a place that would do a good job. I knew most of the nurses on this floor, and they always went the extra mile for my patients. After a few lengthy conversations and lots of help from the hospital staff she managed to make arrangements to dispose of her house and her property (a herculean task, if you consider that she knew no one that she could trust). All in the nick of time, because her lapses of consciousness were frequent by the day of discharge.
Within three days of admission to the nursing home one of my nurse friends called. She was now unresponsive all the time. I made a long-distance diagnosis of hepatic coma. Once the liver fails, the brain quickly follows. I was not able to see her that day, but I made a stop at the nursing home on my way home the next day.
The nurses told me that she had not spoken or eaten for three days; indeed, she had not moved except for breathing. They had kept her clean, and they frequently turned her, and they always spoke to her as if she could understand what was said.
As soon as I saw her, I knew that she was in a deep coma. All her muscles were flaccid. Her breaths were frequent and shallow. I sat on her bed and held her hand. Only as a courtesy, because I knew that she could not understand what I said, I told her who I was, and that I had come to check on her.
Ten seconds passed. She took a deep breath, opened her eyes, and squeezed my fingers. She smiled. The sweetest, most grateful smile that I have ever been the recipient of.
“Thank you,” she said.
She nodded as she spoke. Then she drifted off again.
I left after a few minutes. The night nurse called me at midnight to tell me that she had died.
I know full well that hepatic coma patients typically drift into and out of consciousness. Yet I feel that she was waiting to thank me before she allowed herself to die.
Since then I always assume that patients can hear and understand everything that I say, all the time. After strokes, under anesthesia, in cases of severe brain disease… it does not matter. I will take the time to hold a hand and explain, or ask how they feel, or just say “Hi.” Many times, I have seen other people in the room (particularly younger nurses) look at me as if I were out of my rocker. Sometimes they tell me “She can’t hear you.”
I nod, and I think about the wonderful, unforgettable smile that this woman mustered up for me. The best present that she could have given me as thanks for coordinating her care. An eternal token of gratitude that will persist until it is my turn to do the same.