“Life isn’t fair.
It’s just fairer than death,
We were about to round on Ms. Jones (not her real name). I admitted her the other night after she fell and was found in her bathroom by the aides at her assisted living complex. She was lucky: she didn’t break any bones despite the grapefruit sized hematoma that was forming over her left hip. I learned from the emergency room chart that she was a relatively healthy 93 year old lady with a history only significant for hypertension and atrial fibrillation. I tried to go talk to her and do a physical exam, but she was grumpy and drowsy and wouldn’t cooperate (in her defence, it was maybe 3am and the emergency physician had just given her some dilaudid). I filled out all her admission paperwork and scanned her home medication list. I opted to continue her medications for hypertension and her aspirin, but since her hemoglobin had dropped during her stay in the emergency room from 108 to 86, I thought it prudent to hold her anticoagulant (blood thinner).
When we walked into the room that morning, I was pleasantly surprised to see a well groomed, alert, and very proper English woman sitting up in bed and eating her breakfast.
“Good Morning Ms. Jones,” my staff said. “We are your team of doctors and we are here to see how you are doing.”
“Well, if you want to know about my pain, it is okay. But if you want to know how I’m doing, well I’m rather upset that the nurses won’t give me any hot water for my tea.”
It turns out there was a communication error and the nursing team believed that Ms. Jones was on a thickened fluid diet to minimize the risk of lung aspiration. As this diet is quite common in our patients, we continued to explain to Ms. Jones the rational behind why she wasn’t allowed to drink her tea.
“Well, that just ridiculous! I was just drinking tea the other day and I certainly didn’t choke on it. I don’t see why it is any different today.”
We offered to place Ms. Jones on an “at risk diet” if she insisted on drinking her tea.
“Well doctors, I am 93 years old. What do I have left in my life if I don’t take risks?”
She had a point, I guess. We proceeded with our rounds, ordered the necessary tests and continued on with the day. We thought about re-starting Ms. Jones’ anticoagulation, but her hemoglobin was down to 80, so we held off and sent her for a CT scan instead. The results came in later that day and there were no identified areas of internal bleeding. We decided we were going to restart the medication the next day.
When we rounded the next day, we visited Ms. Jones again. She was happily eating her breakfast and drinking her tea. She complained that she had been feeling increasingly weak over the past month and attributed her fall to that weakness. She commented that it was just part of getting old. Regardless, we asked for a physiotherapist to help Ms. Jones with her mobility and assess if she needed any aids. As planned, I wrote an order in the chart to re-start the anticoagulation. It was all ready to go, but my staff suddenly felt uncertain: She had only been off of it for 3 days. Why not wait one more day and make sure her hemoglobin remains stable. It is a delicate balance trying to decide how to manage these medications for a person with atrial fibrillation who is also at a high risk of bleeding. Without the medications, there is a chance that the heart can throw off blood clots that can cause a stroke. With the medications, however, it becomes difficult to control andy sources of bleeding.
Later that afternoon, I passed by Ms. Jones walking with the physiotherapist and a walker down the halls of the unit. She smiled at me, and I smiled back.
The next day was Friday and we started rounds in the same way we always do. Our team was a little smaller, so we divided up the work and moved a little faster so that everything would get done. We got to Ms. Jones’ chart. The physiotherapist was convinced that she would safely mobilize with a walker. Her hemoglobin had been stable over the past 36 hours, and from all other aspects, it seemed like she was ready to go home. We walked into her room to tell her the good news. However, Ms. Jones was not sitting up in her bed eating her breakfast. Instead, she was laying with her head cocked to her left side, her right leg flexed and rotated to the left, and her right arm motionless by her side. We said hi to her but all she did was moan.
“Ms. Jones, are you alright this morning?”
She just moaned again, this time louder and more persistently. I went to her left side and looked at her. She wanted to say something, but all she could do was moan. She reached for the ID badge dangling from my neck and looked at it. Then she looked at me. And she moaned again. My staff had already left the room and was on the phone with a radiologist requesting a STAT CT scan. But we didn’t really need it to know that Ms. Jones had a stroke, likely sometime overnight.
By the time Ms. Jones’ sons had arrived at the hospital, the results of her CT scan were back: Large right MCA territory infarct.
We explained to her sons what this meant and that given her age and the size of the stoke, she likely had a poor prognosis. We explained the options for her further care and it didn’t take long for them to both agree that their mother would not be happy living the way she was now. The felt that if their mother could talk to them, she would say that it was her time to go.
And just like that, we consulted palliative care for Ms. Jones. We discontinued all her therapeutic medications, and ordered all our comfort care measures. She was moved to a private room. And ever since that day, there has been a constant bedside companion from her family present. I know this because I visit Ms. Jones multiple times a day. She knows who I am and she smiles at me when I tell her that I’ve been thinking about her. Every day she looks more and more like it might be her last day. But every morning her name is still on my list. So I go back to visit her again.
It was the day we were going to send her home, and instead it became the day that determined her death. It isn’t fair.
Ms. Jones was such a fun. happy, feisty little English lady who probably had a few more good years ahed of her. But our medical care failed her and now she is dying. Life isn’t fair.
Every day she slips further and further away. She spends less time awake and I spend more time talking with her family members. They tell me stories about their mom and it makes them happy. Then they turn at look at their dying mother asleep in her death bed, and their voices stop. I let them cry and I place my hand on their shoulder for just the right amount of time. Death is not fair.