Clinical, Featured, Internal Medicine, Palliative Care
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I Think He is Ready

Mrs. Red Jacket sat at the bedside in her isolation gown, which covered her red jacket. She had left her walker outside her husband’s room. She held his hand and gazed out the window while he was sleeping.

As a 92-year-old gentleman, Mr. Red Jacket was transferred from the intensive care unit (ICU) five days prior after recovering from distributive shock secondary to a severe Clostridium difficile infection. I was the senior resident covering the geriatric medicine service.

One week prior, Mr. Red Jacket had been discharged from an outside hospital after completing treatment for a heart failure exacerbation. Since then, his functional status had declined rapidly. Despite being on oral vancomycin, he was suffering from persistent diarrhea associated with poor oral intake, multiple episodes of delirium, and anasarca. Mrs. Red Jacket had already informed the ICU team of her husband’s do not resuscitate (DNR) wishes.

When I entered the patient’s room, Mrs. Red Jacket, with her well-groomed hair, wrinkled cheeks and her own 91 years of age, was holding her husband’s edematous hand. After I asked her to join me at the family room across the hall, she smiled and agreed to my suggestion to discuss her husband’s condition. I helped her use the walker and held her purse as we walked together to the meeting room.

After she sat down, I closed the door and sat on the chair facing her, and my attending physician joined us. We started the goals of care discussion by asking about her understanding of Mr. Red Jacket’s medical condition. Mrs. Red Jacket recognized her husband’s progressive decline in functional capacity and frail status over the past year. She went on to inform us of their 72 years of marriage, and she detailed their first meeting while they were still in high school. With a sigh, the nonagenarian said that Mr. Red Jacket’s father initially refused to allow them to get married. Mrs. Red Jacket smiled and said, “My father-in-law later told me that my husband made the right decision.” With a weak voice, she emphasized that he has always supported her; it was now her time to return the favor. I informed her of Mr. Red Jacket’s present condition and poor prognosis. The attending physician and I explained the options: continue current management, or pursue hospice. Further, I detailed the risks and benefits of each approach. Mrs. Red Jacket recalled an instance during which her husband said that he was ready to see his deceased parents. With this in mind, she expressed an understanding of his condition and elected to pursue hospice measures.

When I went back home that day, I reflected on that discussion in depth and on the wisdom this woman demonstrated. The lesson I learned was that passing away with dignity and comfort carries as much value as living a fulfilling life. A responsibility we have towards our patient is to conduct such discussions about the goal of medical care. Although these topics may be uncomfortable for both the families and physicians, such discussions help us better understand and honor their wishes. The focus shifts to the patient as a human being rather than a disease entity. Knowing about this couple’s marriage and experiences made me better understand their motives and difficulties. This aspect of the discussion allowed me to empathize with their plight and identify with their suffering. This physician’s duty to establish a clear direction and goal of medical care both complement and improve our ability to provide exceptional medical care such as ordering diagnostic studies and employing evidence-based treatment modalities. Engaging patients and their families in this discussion facilitates advanced planning and brings a paradigm shift among health care providers on one side and patients and their families on the other side.

I saw Mrs. Red Jacket the next day talking to the home hospice representative about the necessary logistic arrangements. I did not want to interrupt that discussion, but later that day, when Mrs. Red Jacket was sitting near her husband’s room, I approached her and kneeled so we were face to face. While I was holding her hand, she expressed an appreciation of the medical care that her husband received. She smiled with tearful eyes and said, “I think he is ready.”

Image credit: by truthseeker08 licensed under CC0 1.0.

Gebran Khneizer, MD Gebran Khneizer, MD (1 Posts)

Resident Physician Contributing Writer

Saint Louis University Hospital

Gebran was born and raised in Beirut, Lebanon. He comes from a family of five children, including four sisters. After his volunteering experience at the Children Cancer Center of Lebanon, Gebran decided to pursue pre-medical studies at American University of Beirut. He also attended medical school there. Following that, he pursued postdoctoral research in transplant Nephrology at Johns Hopkins. He completed his residency in Internal Medicine at Saint Louis University hospital. For the love of the Midwest, he plans to move to Indiana University to work in academic hospital medicine. Basketball and scuba diving are some of Gebran's passions. In his free time, he enjoys watching the NBA and buying all the gear for the Cleveland Cavaliers.