Some evenings are like this in the emergency room, filled with so many stories, so much pain that time flies and I forget to eat.
Tonight is not busy, it’s hectic. I barely have time to think.
I flow from one patient to another, hearing stories, listening to heart and lungs, ordering tests, prescribing treatments and hoping for the best, that I make no mistakes.
Sometimes people wait one full day. One. Full. Day. I have to pause to understand the implications of this. They wait one full day, sitting on an uncomfortable chair, with their pain and their worries, to see me. When the number of patients to see much exceeds our capacity to treat , what do we do? We accelerate and we try to treat more, because we care. But there are risks doing so, speeding up… but we take them, because we care. Eventually, something goes wrong. It is just a matter of time before something goes wrong and what happens then, people suffer. We hate this but this is the dilemma we face… we, the emergency room nurses and doctors. We take this impossible pressure and we try to find the right balance, because we care. In every crying child, we see our own. In every lonely elderly, we see our parents. We want to help them all… sometimes we can’t. This is what we do, we care. This is the life that happens in emergency rooms around the world. There is a brotherhood of people out there who deeply understand this feeling.
Ms. Chartrand (fictive name) is an 95-year-old grandmother of four. She was treated in the last year for metastatic breast cancer. Like most people, she has accepted the palliative chemotherapy and radiotherapy to her spine tumors. The last months have been filled with grief. She has seen many of the things we take for granted stolen from her by cancer like the ability to walk. She is grateful to be still able to see, think and talk. This is what she does now with the time left, think and talk. Ms. Chartrand loves life, more so than ever as it fades away. She loves her sons and daughter. She loves her grandchildren. She loves her friends. And all those people love her in return. Her life has meaning even though she can’t walk, even though she endures the pain and griefs that cancer brings.
Ms. Chartrand is lying on a resuscitation bed tonight. The triage nurse hooked her up on a monitor. She has an intravenous line on her arm to give fluids because she hasn’t been eating for 2 days. She’s also been having diarrhea from the last round of chemotherapy. We gave her medication to try to relieve the strong feeling of nausea that is now part of her life.
I come up to her bed to introduce myself.
Hello Ms. Chartrand, I am Dr Pham-Dinh but please call me Martin. She turns toward me and despite all fatigue, the pain in her back and the nausea, she smiles and looks at me… there is an unusual depth in her dark brown eyes. Despite the chaos surrounding us, I take the time to see her. I say nothing but I look closely at these beautiful eyes. I look deeply. I am touched by the strength her gaze. Without a word, I feel a connection. She is filled with life, filled with stories, filled with so many emotions that it’s hard to explain. In these eyes, I see her pain and despair but i also see the depth of her life.
What can I do for you?
Honestly, not much…
Are you in pain?
It’s better now.
What brought you here?
I am dying…
I let a few seconds pass and I hold her gaze.
I hear you…
What would you like me to do?
Let me die… peacefully if possible.
OK. I’ll try…
Do you want the monitor? No.
Do you want the IV? No.
What do you want? I just want to die peacefully, surrounded by people I love.
Her family arrives at the bedside, daughter and her husband. I get a barrage of questions.
What happened? She fell.
Is she hurt? No.
Why is she here in the resuscitation room? She had low blood pressure.
What are her test results? Blood tests were sent during triage but no results are available yet.
You know she has cancer? Yes.
You know she is treated by an oncologist in Quebec and she is on an experimental drug that she must take every day at dinner time, I brought the pills with me.
I look at my patient and she looks away.
Please, let’s sit down and talk.
I understand you are worried about your mother’s condition and you want what’s best for her. Yes, that’s what I want. Will she be transferred to intensive care?
Her systolic blood pressure is still 85, what are you doing about this? She had a urine infection last week treated with an antibiotic, could this be it?
Ms. Lacroix (fictive name), let’s slow down and see what your mother wants. I take her hand and I guide her. Take your mother’s hand and listen. She has something very important to say. Ms. Chartrand turns back toward us, holding her daughter’s hand, she gives her the same gaze I got and says three words: I am dying…
I want to die… I am sorry, there is no way back…
Tears flow, sadness is shared. I take a step back and I say nothing. I let them be together.
She continues…
I have been feeling it for many weeks and I have been trying to say it but we have been caught up in all the hopes created by this experimental treatment that we failed to see this. Since the tumor invaded my leg, I can’t walk. In the last week, I have been losing vision and this headache tells me that the tumor is growing in my brain. Soon enough, I won’t be able to talk or think. I do not want this.
But there are treatments, radiotherapy could help…
No. I’ve had enough.
But… No.
But… NO!
Gaze changed, sadness turned to anger.
I step in.
Ms. Lacroix, I understand your pain and despair, it’s unbearable to see someone we love be in this condition and say something like this.
She loves you very much and so do you.
You need to listen. What your mother is trying to say is that she had enough.
You’ve both cried together.
Now, she really is asking you this simple question:
Can you love me enough to let me go?
Can you simply be with me and hold my hand while I die?
I know how hard it must be for you to accept this but I need this, I am afraid and I want you to be with me while I leave this life.
This is really what she is trying to say tonight. Now, I will give you some time together and i’ll come back to check on you both.
I must go on with my work. These few minutes felt like an eternity, filled with the emotional intensity of a blinding sun.
As hard as it is, it’s also beautiful because this is real life.
Other people have been waiting to see me and I must snap out of this emotional moment and go back to this work I love, to the patients I’ve not seen and who need my help.
I write up a quick note and orders. Do not resuscitate. Transfer out of resuscitation room. Cancel all labs. Remove IV access and monitor. Prioritize admission to palliative care and, until then, if available, find quiet room.
Two hours later, I go back to see Ms. Chartrand. She is still holding her daughter’s hand and they are talking quietly. She seems comfortable and calm.
Is there anything I can do for you? No. I am OK.
I turn to leave the room.
Wait! I need to tell you something.
I turn back and she gives me a different look, filled with gratitude: thank you.
I smile, thank you.
I go back to the flow of my work.
A few hours later, as I am coming back from the resuscitation room, on my way to another patient, I have a quick look and I recognize the irregular breathing patterns and the unusual quietness.
I approach Ms. Lacroix. She is still holding her mother’s hand who is alternating between deep and shallow breaths.
I whisper in her ears: the time has come… she is holding on to you, to your hand. She’ll hold on longer if you keep holding her hand like you do. It’s OK. She loves you and you love her so much, I can see this. When you are ready, get close to her, kiss her softly and whisper in her ear: I love you Mom, it’s OK to let go. We will be OK. And let her hand go when you feel it. You will give her the most beautiful gift of life: a good death.
I sit down for a few minutes and I hold her hand while she gathers the courage to do what needs to be done.
As we sit together, at the edges of life and death, I realize that the privilege of this work, the ultimate gift I received from my patients are these two simple ideas:
Time is a gift.
Love is everything.
Thank you
Disclamer: The story, all names, characters, and incidents portrayed in this story are fictitious. No identification with actual persons (living or deceased), places, buildings, and products is intended or should be inferred. This story has inspired by the many similar stories I’ve had the privilege to be a part of in the 20 years that I’ve practiced medicine.
This podcast is an experiment. If you would like me to produce more, please like, share, visit my blog or write a comment. If the interest is real, I will publish more content. Again, thank you. Martin Pham Dinh
Martin Pham Dinh 