This week was completely devoted to an Internal Medicine review course. My whole schedule was blocked, and I rode the train into town each morning to sit in a lecture room, sip tea, and soak up the knowledge.

It’s been wonderful to sit and be a student again. But, towards the end of this morning’s lectures, I started spacing out. Speakers were speaking and I kept losing track of what they were saying. I think my brain is full. All the rest of the day, my mind wandered. I wasn’t worrying about work or home; rather, I was remembering a handful of past cases.

The talk that spurred the memories was about hospice and palliative care. I’m a fan of both, but I feel like it’s much harder to get patients to either than it should be. Very unfortunately, I’ve seen and been a part of some not very good hospital deaths….

Well over twenty years ago*, I was volunteering in a hospital emergency room. I was an eager pre-med. The ambulance brought in this guy. He was old but not that old, barrel-chested, sitting up and leaning forward, hands clamped on the edges of the gurney, gasping. He was repeating, over and over: “Oh God. Oh God. I’m not ready. I’m not ready. Help me. Help me. Oh God. Oh God.” His face was blueish. He had oxygen on, but it wasn’t making a difference. The emergency attending flipped his chart shut and said, “This guy’s a no-code. Let’s get the family in to say goodbye and get him some morphine already.”

In those years, I lived for doctor TV shows and soaps, and in all of them, everything happens in the emergency room. Patients and families hang out in those Hollywood-spacious rooms forever. Diagnoses and prognoses are made, babies are born, affairs are had, drama happens, and people die with much fanfare. Of course we know that’s all a load of bull. Right?

Well, this guy went out like a TV show. He was some Italian patriarch, dying of emphysema. I can’t help but think that someone in The Family had it in for him, because this was a slow, torturous spectacle. No less than about twenty people paraded through that room to say goodbye, and him all the while gasping: “Oh God. Oh God. I’m not ready. I’m not ready. Help me. Help me.” But the calling hour went on and on, solemn-faced folks shuffling through, and no one seemed upset that he was drowning in the air.

At some point the ER doc got close enough, and the guy’s hand shot out. He grabbed the ER doc by the collar and hoarsely commanded, “Get me the goddamned respirator.” Some flurry of confusion ensued, with family and ER staff all in a tizzy. But the guy said, clear as day, “I changed my mind. Get me the goddamned machine.”

So anesthesia was STAT paged and the ICU staff descended upon the Italian patriarch, who was intubated and sedated, never to awaken again.

The whole scene came back to me during this hospice/palliative care talk, when the speaker asked us, “If you were diagnosed with a terminal illness with a limited life span, would you want to be referred to palliative care and hospice right away?” The whole room of about two hundred practicing physicians nodded affirmative. Hell, yeah. Give me enough morphine, and let me stay home. 

The speaker strongly recommended that we all read Atul Gawande’s book, Being Mortal. I cannot wait to read this, but I’m holding off until after I pass the boards. It will be a treat. I keep hearing about it and reading excerpts and I think it’s going to be an excellent read.

Has anyone read this? And, if you were diagnosed with a terminal illness with a limited life span, would you want to be referred to palliative care and hospice right away?

 

A book to read: http://atulgawande.com/book/being-mortal/

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*These old cases are true. These are from literally two decades ago. Any identifying information has been long forgotten, as well as some details; my imagination has filled some of this in. I trained in five different states and innumerable hospitals, and I’m not particularly worried that anyone will recognize themselves or their family members.