November 21, 2009

• Last Words

  I think there is an unspoken expectation that people at the time of their death will have last words. Some final message they have been waiting to impart, whether it be words of reconciliation for long estranged relatives, or a simple goodbye to those they love. In this archetypal deathbed image, family members are gathered around the bed of the dying, who is clear, lucid, and distills a lifetime of experience into a few words of wisdom before sighing once, and passing on.

  The sad reality is that most people never get a chance to say anything before they die, because they have long since lost the power of speech.

  I recently sent a man home to die. A man who, a mere month ago, I had treated for a relatively straightforward pneumonia. Unfortunately, old age is insidious, and at a certain point, it can become quite hard for individuals to recover even from straightforward diseases. On his readmission, this elderly gentleman stated his pneumonia had resolved, but he still had fatigue. So we admitted him, and began working him up to locate other possible sources of the infection his labs indicated he still had.

  And I spent the next 2 weeks watching him slowly but gradually decline from an interactive, lively, hard of hearing old gentleman breathing on his own to a nonverbal, nonambulating, shell of his former self, lying in bed on oxygen, while the family met with the palliative care team. A thorough inspection had revealed no infectious source, his cardiovascular status had gone from poor to practically nonexsitent, and finally I had the dubious responsibility of telling his family, “I’m sorry, there’s nothing more we can do. Perhaps it’s time you think about taking him home.”

  The family, while saddended by the news (understatement though THAT be) understood, and we discussed the options available before they decided they were in agreement with comfort measures only, a do not resucitate order, and bringing the patient home to die in a familiar setting.

  I signed the discharge orders, knowing I would never see this patient again. I tried harder than I could say to recall when the last conversation I had with him was, reaching to find anything at all that could be construed as last words and not just my one sided questioning of daily symptoms to which he could only respond with nods. I came up with nothing.

  So I sent the family home with last words of my own: Whatever your beliefs are, I sincerely hope that your loved one finds peace and happiness in accordance with them. Then I stepped over to the computer, clicked the order to discharge, and watched as they disappeared forever.

  • 5:08 am
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