Dignity in death

My grandmother died this week. She was 86 years old. She was healthy well into her 80s, living independently, playing her cards games and watching Jeopardy with her grandkids. Two years ago she had an elective shoulder replacement. Therefore, she was luckily in the hospital from that procedure when the GIST tumor in her small intestines caused an obstruction and stretched enough to rupture her small bowel. She had her second surgery in a week at 84 years old, and still came through that well. So that's how we got her diagnosis and began treatment.

The treatment was just too much, and no one argued or disapproved when she elected to stop treatment and stay at home under the care of hospice. We got her a DNR. There were charts and meal wheels. She was never alone for the last 3-4 months. She stayed in her home, slept in her own bed. We gave her morphine and zofran when she needed them. All of us had strict orders NOT to call 911 if she fell or felt ill when we were with her.

She had good days and bad. The last day I saw her was an excellent one. She sat in the living room with several of her children and grandchildren sprawled on the floor around her, "having a party." (I brought the bourbon...) She was totally lucid, cracking jokes (telling my cousin she had a big mouth and couldn't keep a secret...!) The four days immediately after that, she stopped eating, stopped talking and didn't get out of bed until she died.

But she died in her bed, with a little morphine and haldol on board and my uncles at her side. What could be better than that?

I can tell you what's worse. What I do to my patients sometimes. Frequently, in the pursuit of a cure, patients and especially families, inadvertently torture the patient. Let me tell you, there's nothing less dignified than being flogged until your last breath in the ICU.

We put a breathing tube down your throat. If it says in for too long, we cut your throat open and put a trach in. You can't eat in this state, so we put a feeding tube down your nose or a PEG in your abdomen. You've got a foley in your bladder, or worse, you don't have one and are incontinent all over yourself. Similarly, you either have to endure frequently turns and cleaning when you're incontinent of stool or we stick a rectal tube up your rear end. Because you instinctively want to pull all of these things out, we tie your hands down with restraints.

Sometimes we put you on dialysis to help your kidneys. You're on the vent to breathe for you. If your heart is dying, we can pace you. Or put a ventricular assist device in. Or even throw you on ECMO.

The high doses of pressors may cause your toes to turn black and fall off. When your heart stops, I'm going to send high doses of electricity through you and pound on your chest, breaking ribs.

And a lot of times we can save people. Nothing makes me happier than seeing one of my critically ill patients get off dialysis, get their ETT out, regain their native heart rhythm. Then leave the ICU. Go to rehab. And sometimes come back to see us, walking and talking.

But that's not always the outcome. Especially for the elderly. Or the baseline infirm. Or those whose original diagnosis is terminal anyway.

If you ask most medical professionals how they want to die, it's usually more along the lines of how my grandmother did. At home. With family. Without tubes and lines and restraints. On their own terms.

The cure is worth it. But the cure isn't always achievable. We have to know when and where the line is.

Love you Grandmommy