I wasn’t trained for this.
All of us in medicine were taught to battle death to the final breath. We would debate euthanasia practices of foreign climes and those of our veterinarian colleagues with occasional envy and confusion on how one might know when the time was right to let go. We all heard of our hospice nurses who pointedly cautioned their terminal, in-pain patients on how much narcotic not to take.
I have a history of holding on too long. Starting in medical school with fur-babies to whom I administered daily subcutaneous saline, insulin and home-produced renal diets, or debated diagnostic laparotomies to determine feline Crohn’s versus lymphoma (the latter more likely), I acknowledge that I frequently held on too long to my loves for my own selfish needs.
My granddad (we called him GrandDOM, for dirty old man— he wasn’t, but did share a love of pull-my-finger humor and “break glass in case of emergency” corncob bathroom decor) died after a six-month battle with metastatic pancreatic cancer while I was in my first year of GI fellowship. My mother practically needed to pry him from the hospital, as they wouldn’t release him with an indwelling biliary catheter and a fever of unknown origin; they wanted to continue rotating antibiotics and consider chemotherapy in a deeply jaundiced 86-year-old. Thank goodness mom was brave and bold, and kept GrandDOM in comfort in their home for his final months. I agreed that further hospitalization was futile, but I was frightened and heartbroken that my beloved gastroenterology could not make him more comfortable or buy him extra time.
I lost my dad to disease related to his tobacco use; despite his own father succumbing to mouth cancer, Dad simply couldn’t quit smoking. He had a quadruple bypass and still didn’t quit, smoking on the down-low while attending his model- train club. Laryngeal cancer? I’m afraid that he continued his burning cancer sticks, even via his laryngeal stoma — I wince at the mental image. I’m afraid he couldn’t see the point of nicotine withdrawal — he later said that he fully expected to die as early as his father had from “tobacco-use disorder” (a pretty sanitized name for a difficult-to-break, nasty addiction) and was woefully surprised to last about seven more years after his laryngectomy.
I was alerted by a phone call from Mom that Dad had visited the ED the previous day — an unheard of occurrence for my stoic pop — for weakness and shortness of breath, and he was found to be profoundly anemic. He refused hospitalization or transfusion. I hopped an evening flight from Virginia to Florida to fix this apparent GI issue; after all, who better than a gastroenterologist to manage anemia?
We took my pallid and weakened Dad, who didn’t make his usual objections, back to the ED, where they confirmed his profound anemia and admitted him to the floor. He had just arrived to the room and had yet to be checked in by the staff when he suffered a respiratory arrest, and as the sole person in the room who knew the relevant medical history, I found myself presiding over the code. Dad was intubated and moved to the ICU — precisely where and how he had told me he wished never to be.
With conversation with the intensivist and Dad’s internist, and looking at his profound acidosis, the three of us decided we would give Dad one hour on the ventilator to reverse the acidosis and hopefully benefit from deep suctioning. If there was no improvement, we would discontinue the ventilator — a bit belatedly but in accord with Dad’s wishes — and allow him to go.
The repeat blood gas showed no improvement, so Dad’s laryngeal stoma was extubated, and the family received liberal bedside privileges in the ICU. We gathered at bedside and shared stories of growing up with our complex and brilliant father. And his death lingered.
Several times I was approached by the intensivist warning me that if he remained alive by morning he would be moved to a step-down floor, and consideration for transfer to a nursing home under hospice would begin. The nurses, being supportive, would murmur in my ear that if I would like, they could give a dose of IV morphine to help with “anxiety from air hunger.” I simply couldn’t give the order. Dad appeared comfortable, the outcome was a forgone conclusion, but I simply couldn’t give the okay to euthanize him. He died about 0200, directly after my younger brother Michael had left the hospital to get my mom home.
I am faced with loss again. My mom is a healthy 90 years old but is beginning to “slip a bit,” mentally. Her internist says it’s not dementia, but rather, normal aging. Mom insists this summer she wants to return to her summer home in the in the mountains of North Carolina, with its twisty-turny roads, despite a recent diagnosis of wet macular degeneration in her
one remaining good eye, requiring intraocular, anti-vascular shots monthly. Her friends have all died or moved down to the flatlands. At her Florida condo, her friends have died or moved on. We, her children, have carefully started to discuss a retirement home close to my brothers in Orlando, with in- house activities, transportation and nearness to the family (and to the great-granddaughter with a second in the oven). But it’s difficult; I believe her resistance is concern over loss of autonomy and change.
I just returned home from a major blessing: the opportunity to travel with my mom on a 14-day river cruise of the Netherlands and Belgium. It was wonderful to travel with Mom, my older brother, Robert, and my sister-in-law, but because we were outside of Mom’s normal venues, her confusion was more obvious. If I didn’t keep her in reach on our walking tours, she would head off in a random direction. She became trapped in two travel bathrooms (one airline, one tram station), unable to unlock the door and needing assistance to exit. I mislaid her for fifteen endless minutes in the crowded Keukenhof flower gardens when she was swept away in a different tour group.
The others on our tour were kind with her, gently tapping her shoulder to direct her and waving her ahead to board buses and boats. On our return home, both she and Robert contracted COVID-19; Mom’s case was moderate, and she became confused and disoriented in her illness, although not hypoxic or in need of hospitalization. My younger brother, Michael, drove to Daytona to help assess her, participate in an urgent telehealth appointment, and bring her to his Orlando home for close watch. She has since recovered, although she has a persistent and concerning hacking cough. She will delay her return to North Carolina, but instead plans to come stay with me in Virginia for a bit until she is better before proceeding to what I believe will be her final summer in the mountains.
So I’m faced with an upcoming inevitable loss of love — akin to a slow-moving freight train approaching where our family sits, stuck on the tracks. However, my own age seems to have birthed some degree of wisdom; I can permit feeling sorrow without erecting a wall of science between me and the upcoming loss. I have learned to embrace the sadness and not buffer it.
I am learning to let go.
