Sue went to the operating room today, which was not at all what I recommended, not that we ever discussed my personal opinion on the matter. With a worsening small bowel obstruction, I woke up this morning and, realizing that matters had worsened overnight, I called her husband, Dave. I don’t think I woke him, but his voice, one complicated by little, if any, sleep and likely hours of talking with family members, sounded like I felt—gravelly and hoarse.
I shared with Dave that, if we were going to attempt surgery, the moment had arrived. I did not recommend this intervention but contrasted it with the other choice: to make Sue comfortable, recognizing that her condition would continue its squeezing, ischemic march towards death. That was not overly dramatic; this bowel obstruction was terminal.
Arriving on the fourth floor of the Berkeley Medical Center around 11:30, I cleaned my hands with sanitizer slowly while standing in the doorway. One, two, three family members whom I did not know, but who bore a striking resemblance to my patient, turned around with expectant gazes. I walked, wiping my hands as a path was cleared for my arrival.
Eight family members gathered in her hospital room, and I was grateful to address them before the treacherous trek to the OR. I had finished yesterday’s endless day with the words of my general surgery colleague: “Execution by surgery.” He privately confided to me, “I did not share these particular words with the family.”
Years ago, at this moment, I would have focused on vital signs, labs, diagnostic tests, and whatnot. Today, my responsibility was leading this family across a rickety and slippery bridge, the one that took their mother (who was still able to talk to me) and ferried her across a steep chasm. On the other side was a ventilator in the ICU. I had little doubt about my surgical colleague’s ability to resect her necrotic bowel and give her an ostomy, but everything after that was in doubt. Or maybe, to me, it was all but certain.
Families intuitively understand these grave situations, and more data was unnecessary. I shook everyone’s hand, introduced myself, and, once all eyes were on me, I acknowledged the gravity of this moment. I told everyone that I was grateful for us to speak together.
Once again, I reviewed the stark choices: a dangerous surgery on one side and a palliative care plan on the other. I tended to do things this way, to see, whenever possible, my patient’s face. Sue was firm in her decision to not “just accept this illness and go on and die.” I made known my appreciation for her ability to make her choice and how it was important for me to know that she understood. And she did.
Before praying with this family, a moment in which the spirit swelled and expanded the interior of room 413B, I explained how Sue would go to the ICU, and I mentioned a colleague by name who would care for her there. I described some of the pitfalls—blood clots, heart attacks, strokes, and other events that worried me. I let this sink in with the family, but what I really did was provide an architecture to the worries that vibrated deep in their hearts, the ones for which they did not have words. I told Sue that, as a matriarch who loved playing bridge and rooting for the Orioles, she could make her own decisions, and I would respect them.
I asked the family if I could pray with them, and somehow, I held back the tears long enough to fumble my way through. With their eyes closed and holding my hand, Sue’s kids may have prayed for a miracle. I could taste the desperate energy, the bargaining, the begging. At this moment, I could almost see it, heavy and thick in this cramped room. The spirit filled me and guided whatever came out of my mouth afterward.
I, on the other hand, did not attempt to phone in a divine rescue helicopter but rather prayed for the family, who squeezed hands hard as one does when walking along a slippery, steep, wet, broken-down path. The last few days had produced an avalanche of pain, contemplation of mortality, and a world in which their mother ceased to exist.
Having stared across this precipice before, I knew my prayers and my healing presence were for those who were going to be left behind. Because that was what, I knew in my doctor’s heart, was about to happen. I had no doubt what this family needed from me.
I assumed this would be the last time I saw Sue. “I love you,” and the tears came. I no longer kept it together, whatever that meant. I sensed shock in the family at my behavior—this doctor who cried and prayed as if he were just another kid in this family. I let my white-coat professionalism dissolve in a stream of tears and form a puddle on the floor. I had done my duty, the one I devoted my life to doing, and I gave myself permission to simply be a human being.
As I left the room and became more and more choked up as I walked down the hallway, I hoped and prayed that, when these family members witnessed my respect for this incredible matriarch, like they had done all their lives, they had some degree of acceptance that Sue had chosen the only path forward that made sense for her.
Ryan McCarthy is an internal medicine physician.
