Power
…adapted from Gray’s Anatomy of the Human Body, Henry Gray, 1918…
“He’s getting pretty bad…we may have no choice but to intubate him soon,” the fellow circles a few values on the ABG and looks through the glass door at the severely underweight 30-something leaning into his face mask, oxygen on full. ”And we may not be able to extubate him this time.”
The senior resident nods and flips through the chart.
“He still doesn’t have a POA…and no advanced directive, either. I know last time he was here we discussed that this situation was coming and that he really should make his wishes known before it did… He wanted none of it.”
Both young men, men the same age as the patient concentrating on breathing in the ICU bed, sigh. I follow the senior into the room where the patient sits with his wife and brother. They are so used to this environment they look stoic, nonchalant even. Wife flips through an issue of Cosmo. Brother is absorbed by scenes from an upcoming Pickers on the wall mounted TV.
The senior greets them all as old friends, inquires about the dog, the niece, the newly remodeled kitchen, then quickly rehashes the history of the present illness and runs through the plan for the day. Everyone nods like it’s old hat. Because, for them, it is.
“So, if gets to the point that you need to be intubated again, we will do that, with your permission, of course.”
The patient nods incredulously.
“Well, of course,” his breathy words ring out.
“OK, very good, we always like to get your permission…And now there is something we really need to discuss. We’ve discussed it before, but it’s important that I bring it up again.”
The patient’s eyes narrow, becoming fierce in spite of their sickly, glassy appearance. His 90-pound frame tenses as much as his advanced cachexia will allow.
“We know it’s very possible that this time or sometime very soon something may happen so that you will not be able to make your wishes known. It’s important that you consider either putting down on paper what you would like to happen in this situation, or legally appointing someone who knows your wishes to speak for you. We call these documents the advanced directive and the legal health care power of attorney. They are ways for you to help guide your healthcare at a time you cannot communicate your wishes to us.”
Wife and brother’s eyes are now as wide as saucers. They stare at the senior in blank surprise. Mr. Jones is glaring in the general direction of the door.
The senior takes a step back.
“Mr. Jones, I believe your pulmonologist is Dr. Lungs. What has she told you about your condition?”
Mr. Jones tears the mask from his face.
“Now is not the time!” he whisper screams, pointing with a trembling, claw-like finger toward the door.
He grasps the mask stubbornly in his lap until we have exited, then replaces it and struggles for breath, gulping the oxygen into his hungry, dying lungs, eyes squeezed shut with effort.
Wife opens her Cosmo again. Brother changes the channel.
9 Comments on “Power”
Keep it clean, keep it respectful, or keep away.
Because I Can’t Snap
House Rules
Nothing under the table.
Denial comes from fear of facing the unthinkable. It is very potent.
Scott
Indeed – it is righteous and wicked all at once.
very powerful post — I understand — it does not have to make sense
I think it is powerful in that it is utterly relatable – we’ve all been there, some in situations starker than others, and it’s that postponed pain that we all welcome…
Reblogged this on samuel njatha.
I feel more and more as though the time when people have to make end-of-life decisions is exactly the time they are least equipped to do it. As a society I think we tend to avoid thinking about death until it is staring us in the face, and at that point there are so many things going on that many of us become overwhelmed and emotionally paralyzed.
End-of-life care needs to be something discussed in the PCPs office, not in the hospital when it is already too late. Even better — we need to become more comfortable discussing these things outside of the hospital, in community settings — for example, talking about what one wants at the end of life could be done in churches or other community organizations. Unfortunately, we seem to feel that talking about such things is morbid and so most people avoid it.
How exactly to open these conversations earlier — in the PCPs office, in the community, etc — is the hard part.
Thank you for this post.
Sing it, E, sing it!
My husband – a resident physician in an internal medicine-geriatrics combined residency-fellowship who has a passion for primary care – and I have this conversation often — and he has always made a point of having it with all his new patients, healthy or not. It’s a tough subject to broach, no matter how well you know a person or how fabulous you are at talking about the end with those people with whom your relationship has just begun. And I think you put it quite well in branding the feeling accompanying EOL discussions when that end is near a sort of emotional paralysis.
These discussions are best had with a PCP early on in the doctor-patient-relationship, talked about like pap smears and mammograms and vaccinations and other routine health maintenance. And if there is no PCP, specialists who manage chronic or terminal conditions need to stand in and address EOL care in a timely fashion.
The bottom line is both physicians and patients should prepare for this discussion. Once you hit the big 5-0 you expect the colonoscopy talk, the mammogram talk, and doctors are trained to have that talk. We screen and try to prevent disease; why don’t we screen for misconceptions and confusion about EOL issues and document wishes to prevent heartache and mishap and undue fear later? We need to start expecting – demanding – that EOL issues are properly addressed long before they’re a real issue….
Thanks for dropping by, and for your spot on comment!
So descriptive! Felt like I was there as you described it. Powerful and beautiful.
How kind, thank you! The little things – expressions, mannerisms, inflections – it’s those things described that put me there in a scene. Much like you so wonderfully capture the little things in your great snaps!