Love and Anger in Healthcare at The End of Life

By thirdAGE

Medical school and medical training attempt to teach subjective humans how to think and practice medicine objectively. This may be one of the unique fallacies of modern medicine but that’s a subject for different blog. Nevertheless, even in the highly emotional field of emergency medicine I’m usually pretty “chill.” That is, until someone’s dying, and then all of my equanimity can go flying out the window, for better or worse.

Such was the case of Mr. G:

I was waiting out the last five minutes of my night shift, the last of a string of three night shifts in a row. Needless to say, I was chomping at the bit to walk through the exit doors.

While staring impatiently at my watch,  I heard the nurse call out to me, “Dr. Murphy they’re bringing a dying man to room 39 who had a DNR order in the hospital but the nursing home said that has been revoked and are sending him in for a full treatment.”

Immediately, my blood was boiling. I ripped off my watch and threw it in my bag… So much for being chill.

I stood angrily in the hallway, posed in my white coat with hands on hips awaiting the paramedics who were delivering the dying man to me. I was ready to find out exactly whom I should call to reprimand if this was a case of disobedience to patient wishes.

But the minute they turned the corner all of my anger dropped to the floor like a heavy cloak. My heart opened wide at the site of this man, my patient. Mr. G was lying nearly flaccidly on the stretcher gazing upward toward the ceiling. His trembling hands lay at his side and his trembling lips offered an inaudible whisper. I felt great love for him.

I generally naturally feel care and concern for most of my patients. But there’s something different about my dying patients. I feel love when I am near them. Sometimes this particular love sensation is even my first clue that someone is dying.

I leaned in and asked him in my kindest voice, “Mr. G , do you feel any pain? Do you hurt anywhere? Do you feel short of breath?”

He whispered, “No” to each question but could offer no other words. Feeling satisfied that he probably had no distressing symptoms that I needed to manage immediately,  I turned my attention to his paperwork.

He had just been discharged from our hospital to a local skilled care facility and these were the physician orders written in his chart at time of discharge :

“DNR (Do Not Resuscitate.) Do not return to hospital. Comfort care only if condition deteriorates.”

My blood returned to its previous boiling state…

I checked his discharge summary, which read something like this: Mr. G has stage four cancer and multiple metastases, he has elected to discontinue dialysis for his end-stage renal disease due to rapidly declining quality-of-life and would like an “Allow Natural Death /Do Not Resuscitate” order. At this time, he desires only comfort measures. He is fully conscious at the time of this decision. He is estranged from all of his family and there are no other people available to support him in his decision-making process.

He will be discharged to a local facility for supportive care. Per his wishes, he will not be transferred back to the hospital.

I put down all of this paperwork in a neatly folded stack and went to stand by Mr G. I gently placed my hand on his shoulder. Again, my anger receded and I felt love.

Standing quietly beside him, it dawned upon me that I might be the singular person in the world “available to support him” in his previous “decision-making process.” I might be his only advocate now. And I might be the last person to love him before he dies.

***

3 lessons from Mr. G:

1- Emotional subjectivity, empathy, and love allow us to enter into the lives of our patients as potential advocates for them if our emotions are regarded as tools for greater service.

2- Anger and moral outrage may be harnessed to transform healthcare systems.

3- Used conscientiously, love and anger both have a place in improving the practice of medicine and supporting the patient’s experience at the end of life.

(As always names and some details have been changed to protect the privacy of the patient. Date of post has no relevance to the date of the patient encounter.)

Dr. Monica Williams-Murphy, a Board Certified Emergency Medicine Physician, practices in one of the largest emergency departments in the United States. Visit her website, www.oktodie.com, to learn more about the book she-coauthored, It’s OK to Die.