18663 Ventura Blvd, Suite 202, Tarzana CA 91356

Thursday, August 02, 2007

Going in Peace

I don't share deeply personal stories on this blog. But I want to share this one because of the impact that it has had on me, being the family member of an ill patient rather than the physician.

My grandmother was the healthiest 92 year-old woman I knew. An avid shopper, she walked on the treadmill for 30 minutes every day and went out to dinner with her friends on Saturday night. She lived independently in her own apartment. She looked in on her 88 year-old little sister who lived down the hallway. Until last Thursday.

She was leaving the dining hall when she fell. She hit her head. She was confused. She was emergently taken to the nearby hospital. The CT scan showed "a little bleeding", I was told. Keep in mind that I'm in Los Angeles and my grandmother is in Michigan. She's waking up, my mom says.

The next morning, I'm told she has bleeding in her brainstem, but "they're still not sure" what is going on. But my grandmother was awake and alert, though she had a lot of bruising from the fall. My brother, who also lives in LA, and I booked a flight to leave that night.

The next morning, my brother and I were at my grandmother's side. I could barely recognize her, with the right side of her face drooping and bruised. She opened her left eye when I spoke to her and held her hand; she said my name. Then she said my brother's name.

Shortly after that, she recognized none of us. It became apparent that she was fading. Several doctors came in, none offering much explanation of what had occurred. But their optimism was disturbing. A brainstem bleed in an elderly woman who was clearly getting worse was very very bad. One doctor talked of the possibility of doing an invasive procedure called a transesophageal echocardiogram. The neurologist, when I asked him point blank what my grandmother's prognosis was (I had a pretty good idea, but wanted to hear his thoughts) said, "We'll see in a couple days."

I didn't feel like the doctors were realistic with us. I didn't appreciate the euphemisms and false hope. I wanted them to be more honest about what her prognosis was and not overly optimistic in fear of shocking us.

Then she had periods of apnea -- in other words, she would not breathe for up to forty seconds at a time. The ICU nurse, who took wonderful care of my grandmother, came in and asked what we wanted to do, did we want to consider having my grandmother put on a breathing machine. No, my mother said, my grandmother would not want that, and at that time, with none of her physicians there, we decided to pursue comfort care only -- no more invasive tests, no blood draws, accepting that this is a terminal process.

There were some terrific nurses who cared for my grandmother. But other caregivers were less than great. I overheard that my grandmother's primary physician considered more than two milligrams to be "way too much" morphine. She was grimacing in pain and needed more medicine. A nurse elsewhere refused to increase a morphine drip, insisting wrongly that the hospice physician would not permit more medication.

It's hard sometimes to be a caring family member and a doctor at the same time. The hospice nurse said to me when I was discussing my grandmother's medical status, "Be her granddaughter." But I couldn't just stand by idly and watch -- there were times when my knowledge as a physician led me to speak up. I requested morphine before my grandmother was moved from one bed to another, to cover the pain that the move would involve. When she started to have rattling with her breathing, I requested a scopolamine patch. When her mouth was dry and crusted, I asked the nursing staff to please swab her mouth. Would those things have been done for her comfort if I wasn't standing by? I'm not so sure.

Was I, a cardiologist, intimidating? Did my brother, the attorney, compound that? Perhaps.

My grandmother died in peace early on Tuesday morning. She was comfortable. Of course I am sad, but I know that she didn't linger in pain. She passed away surrounded by those who loved her.

From this experience, I feel more like I can empathize with family members of ill patients. I want to continue to be honest -- at times, I've feared that I'm too honest or too blunt, but that's what my family wanted, not false hope. And I hope I can better think about the details that matter in keeping patients comfortable.


herself75 said...

I am so sorry for your loss. It sounds like your Grandmother left you with the gifts you need to help your patients and their families. my thoughts are with you adn your family.

lonna said...

I'm so sorry for your loss too. When my grandfather was dying, we had to ask for all sorts of things to keep him comfortable too. I teach a course on the psychology of aging and there's lots of current research suggesting that patients and families do better when they know the real truth. That way they can make real plans, both psychologically and in other ways.

Jessica said...

My sympathy to you and your family on your loss. Thanks for sharing such a personal experience - if you can remember these feelings with your grandmother, you are sure to be a better, more empathetic doc to your patients and their families.

Saoirse said...

You have my deepest sympathies. I am glad that her passing was peaceful.

VeggieGirl said...

my heart goes out to you and your family - my grandfather just turned 90 a few weeks ago, and is blessed with good health (like your grandmother was) - I always worry that something tragic could happen (like how your grandmother fell). fortunately you have all the memories of your time with her to reflect upon, and know she's watching over you.

Okra Mary said...

First off, my condolences to you and your family.

And I think your actions sounded right on. If I were a doctor, rather than feel threatened, I would welcome a family member that could understand my jargon and translate that to the rest of the family.

My grandmother died just last year - from a brain injury she suffered in a fall. A similar situation.

If I wasn't there nagging the nurses in the step-down unit to swab her mouth, she would have been in a much more uncomfortable situation.

At one point I walked in and found a tourniquet that was left on her arm for over an hour. She died the next morning. I only wonder if I'd spoken up more if the nurses wouldn't have been so absent-minded.

Though the nurses in the ICU were wonderful - but when she was moved the care seemed to do a 180.

Andrew Keese said...

That was a very touching story. Your grandmother was lucky to have you as a granddaughter. I understand your feeling about being glad she didn't linger in pain. When my grandmother died, I actually felt happy for her. She had recently suffered a stroke, she had a broken hip that doctors didn't want to operate on for fear of hurting her and she had emphysema. It was her time to go.

Xavier Emmanuelle said...

Oh Heather, I'm so sorry.

Scott said...

HaMakom yenachem et'chem b'toch shar avay'lay Tzion vee'Yerushalayim.

(May the Omnipresent comfort you among the mourners of Zion and Jerusalem.)

Anonymous said...

As someone who has lost many many relatives, I would truly appreciate honesty in the doctor. You may be too blunt, but that is way more humane than false hope..believe me. My sympathy and wish for peace for you and your family.

Missy said...

In times of trouble may you be at peace. As a fellow member of the healthcare team, I appaud you for standing up for what you believe and mandating that proper pain medication be given. I don't understand the avoidance we have toward Morphine and other pain medications in times that warrant them. Our healthcare system sometimes forgets that patients are people, not objects. May the many happy memories of your grandmother remain highlighted in your mind forever.

KathyF said...

I'm sorry for you loss. I lost my mom in May.

I'm not a doctor, but I often found myself in a similar position concerning her care. She had Huntington's and I found I knew more than her primary care physicians, who often dc'd meds her neuro prescribed (without informing me). Her carers from Hospice were great, however.

Thanks for sharing, and again, my sympathies.

KleoPatra said...

i'm sorry for your loss, Heather. Your grandmother was a lovely lady - and very loved.

And, also, what scott said....