I was asked to see a 95 year old lady with severe abdominal pain a few weeks ago. She had been admitted to the hospital with complaints of fatigue and chest palpitations. Suddenly one morning she developed severe, sharp abdominal pain. Her heart was racing in the 130's. The Xray technicians were just leaving her room when I arrived. Now I know what you're thinking: 95 years old, what the hell is a surgeon doing on the case? But this was a sharp old broad, entirely in control of faculties. She grabbed my ID to make sure she heard my name correctly. "I'm in a hell of a lot of pain doctor", she said.
Her code status was DNR-CCA, meaning that, in the event of cardiac or pulmonary arrest no invasive life saving maneuvers were to be done. When I pushed on her belly the diagnosis was clear enough. She had peritonitis, likely from a perforated ulcer or perhaps diverticulitis. The x-ray eventually confirmed free air. I quietly informed the lady of her predicament. She told me to hold my horses, as her daughter (POA) was on her way in.
I spoke with the daughter on the phone to prepare her. I told her that her mother had sustained a catastrophic intra-abdominal event. I further told her that time was of the utmost importance; we had to determine how aggressive we were going to be, ASAP.
We met at the bedside. The daughter looked understandably strung out and stressed. Her eyes were raw red open wounds. She had seized her mother's pale hand with two of her own, as if she was fervently praying. "I think she wants you to do the operation", was the first thing the daughter said to me. Her voice trembled. She wouldn't let go of her mother's hand. She looked like she had run up the four flights of stairs to get here.
This is where the art of medicine comes into play. I have made the mistake of operating in this situation before, when I was a less experienced surgeon. I used to think it was enough to objectively present patients/families with the options, like a mechanic at a oil change shop. Option A, operate with certain complication rates, including the possibility of death. Option B, palliative care with death to ensue sometime soon. It's your decision. I will support whatever it is you decide. And then to step back, put the onus of responsibility on their shoulders. Sometimes the choice is too overwhelming. The patient is suffering. Please just do whatever will make the pain stop, she pleads to her daughter. What if the pain medications dont work they wonder. Maybe she will be one of those rare patients who survive the surgery and get better. After all, Mom just had lunch with me yesterday at Olive Garden. And so doubt begins to creep in. Doubt about advanced directives and code status orders. It's one thing to fill out end of life documents in an abstract, detached manner years beforehand. It's quite another when actual life rears its unyielding head and strikes at you with its ferocious inexorability. And so adult children of these dying elderly patients will ask----can you save my mom?
I have saved a few. I remember one 89 year old guy I operated on for toxic megacolon. He miraculously survived the subtotal colectomy and was sent to a nursing home. I remembered him as a personal triumph, a transient victory over the brute relentlessness of death. I may have even blogged about it, I can't remember. The story didn't have a happy ending though. I got consulted to see him 8 months after that miracle surgery. He was in the ICU with sepsis from a decubitus ulcer. His granddaughter told me he never really regained his mental or full physical faculties after the surgery, despite the intense rehab. The ileostomy was a constant source of stress and irritation. He had slowly withdrawn into himself and rarely left his bed. He had become a living ghost of the man she had grown up with. He died shortly thereafter.
Sometimes you have an obligation to present a patient's options in such a way that sort of pushes them in one direction over the other. Call it paternalistic if you will. I call it humane.
I told her that an operation would be very difficult (she had had numerous previous surgeries over the years and had an obvious large ventral hernia). I told her that it's certain she would leave the operating room intubated and highly likely that she might never get off the ventilator safely. I told her that many of her organ systems were already starting to fail and that often that process was irreversible, especially in someone her age. I told her that aggressive pain control was an intervention in itself, that she ought not to consider simple pain alleviation as "doing nothing". I told her I would support their ultimate decision....but a surgery would be very tough for her to tolerate.
Well, I've never been one to drag things out, she said. Get me some pain medicine. I don't want any surgery. What are you crying for, she said softly to her daughter. When it's time, it's time.
I sometimes forget how courageous human beings can be if you give them the chance.