The patient was wheeled into the ER by her daughter, who was fraught with worry. "She's been so tired these last few days, I don't know what's wrong with her."
Though she was weak, "Mary" got herself from the wheelchair to the gurney and laid down. The daughter and granddaughter sat in chair at the end of the bed, many questions ensued, their faces showing the apprehension they held.
Mary denied pain, her labs were fairly benign. Her blood pressure was low, heart rate high but no fever, not septic. In her early 70's, she smiled and quietly chatted with me when I entered her room.
She got fluids, warm blankets. Family interacted with their smart phones, watched tv, chatted with Mary when she wasn't sleeping. Their chairs were at the foot of the bed.
She wasn't getting worse, but she wasn't getting better. We'd give it more time and if she didn't turn around, she'd get admitted to the hospital.
Mary had water, some applesauce and more rest. I chatted with the family more. Mary was staying with her daughter for "a month or so". They'd gone through her "important papers" and banking information. The daughter said her mother had told her they needed to put them in order.
More conversations took place. I learned she'd brought pictures with her, given them to family members. She'd shared stories they had not heard before. The two nights before, she had dreamt of her husband and her mother who had died years before. She has spoken of going home. The daughter planned to take her back home the following weekend but they wanted to get her checked out before, because she was so tired.
It was obvious to me that Mary had been preparing for her death, that she was approaching the end of her life on her own terms. Visiting her daughter, putting her affairs in order with her, telling stories, giving pictures, and especially, the dreams.
So we talked. We talked openly about end of life, about death. Mary relaxed, smiled at her daughter and granddaughter.
When the doctor came to bedside, they again spoke openly. Mary didn't want to be admitted, she didn't want fluids or medicine, she asked if it was okay to want this. I realized that what Mary needed was for the doctor to offer refusing treatment. Once this happened, she asked her daughter and granddaughter for their blessing.
A curious thing happened, it happens with all the patients I've seen transition from "treatment" to "comfort care". The chairs moved closer to the gurney, hands were held, I heard and saw more love, more touching. The television turned off, social media became less important.
The experience became more intimate, less clinical. We had orders for the usual comfort care medications, Mary refused all. An hour or so went by.
The chaplain came. As last rites were said, Mary died. Her daughter, granddaughter and another four or five family members were at her bedside, praying, holding hands, sharing their love.
Mary could have been admitted. She didn't want to be, but it took having a conversation with her to figure that out.
As providers, we need to be able to have these conversations comfortably and compassionately.