The Hardest Time

I had tried everything I knew and nothing had worked. My patient, 62 year old Caroline, was still tied to the respirator for her every breath. We had tried all the different ventilator weaning techniques, all the drugs that could reduce her cardiac load and enhance her lung function, all the various medications that would dry out the excess secretions in her respiratory tract without over burdening her already over worked kidneys. Everything had failed. Her vital organs were a row of dominoes, waiting to be tipped over, the slightest nudge resulting in catastrophic failure for her failing heart, decimated lungs and over taxed kidneys. The real tragedy was that Caroline was fully oriented and was aware of everything that was happening to her.

By the time you get to my level of training and clinical experience, you have seen this situation dozens of times. You have dealt with your own feelings of helplessness, even inadequacy, time and time again; and you have tried to help the patients and their families through this one last crisis. But somehow it never gets easier.

I had to speak to Caroline’s daughter, Nancy, herself the mother of a three year old girl and now seven months pregnant. She made the one hour and forty minute drive from her home to the hospital four times a week along the Mass Pike, a highway rated as the number one worst road for commuters in the nation. It was even worse than the famously crowded roads in LA, and this poor pregnant woman was doing it four times a week. Nancy would read to her mom, play her favorite music on a portable CD player she had bought for her room, and show her pictures of her granddaughter. Nancy would also tell her mom of the latest visit to the obstetrician’s office and the current status of her soon to be born baby.

Nancy, Pam the social worker, and I sat in Pam’s small office. Nancy was looking to me expectantly, with hope in her eyes. I felt so inadequate.

“Sometimes,” I said, “we reach a point in time that is the most difficult of all, the time where we must realize there is nothing more we can do. In medicine, as advanced as it is, we eventually are helpless to change the outcome of certain diseases. It’s a time when we feel totally powerless and helpless, and it is sometimes extremely difficult for the family and caregivers to accept. Nancy, we have reached that point with your mom.”

Nancy started to cry, tears slowly rolling down pink cheeks, swollen from pregnancy. I put my hand on her forearm and gave her some tissues. She wiped her eyes while tears continued streaming down. After a minute she could speak slowly, voice quavering.

“What about the other doctors? All the consultants?”

“We have tried everything, Nancy. Every idea, every medication, and every technique we thought had a chance of working.”

She nodded. She knew all this of course, because I had discussed each option with her and her mom before we tried it.

“So there is nothing to do?”

“No,” I said gently, “now is the hardest time of all.”

“Will she live to see her new grandchild? It’s only two more months.”

My heart wanted to break, but I had to be truthful. Caroline’s lungs we totally compromised, her heart was already in failure despite all the medications, and all the lab tests showed her kidneys were starting to fail too. The thing about the heart, lungs and kidneys is that they are all interdependent on each other, almost like a three legged stool, and if one fails, the other two soon follow.

“There is a chance that your mom could see her new grandchild, but it’s a small one.”

“Does mom know all this?”

“No Nancy, I thought we should talk first.” As I looked at her I could see she was willing herself to be strong, to calm herself before seeing her mother. I was amazed at the transformation in just a few seconds. She was just so strong. I could see how this very pregnant woman would drop her three year old off at a baby sitters several times a week and make the long arduous drive on the most heavily traveled road in the country to see her dying mom.

“Can we tell her together?” Her eyes were shining either with tears or determination, I couldn’t tell which. I offered her my arm, she took it and leaned on me as we walked down the corridor to talk to her mom.