For his last seven days I was the first face he and his wife saw in the morning.
He was admitted for uncontrolled atrial fibrillation with rapid ventricular response. At 69 he was a man riddled with cancer. Stage IV pancreatic cancer that had metastasized by the time of diagnosis.
His case was complicated. He was fluid overloaded but intravascularly depleted. His Afib combined with his diastolic heart failure caused his heart to be unable to fill, resulting in hypotension. At the same time our meds to control his rhythm and rate tanked his BP. When we tried to get off some of the extra fluid from his lungs and legs he developed worsening AKI from volume depletion. We switched him to digoxin, but his kidney failure resulted in rapid development of supratheraputic levels and hyperkalemia. We started midodrine and sotalol, finally controlling his heart rate but throwing it the other direction with rates in the 30’s.
Every morning would start out the same way.
“How are you feeling today sir?”
“Fine ma’am, just tired.”
His severe back pain from the bony metastasis combined with orthopnea caused him to only be able to sleep sitting up in a chair with his head leaned forward over a table.
“Any chest pain, shortness of breath, nausea or vomiting?”
Then I would listen to his heart (in its textbook irregular irregular rhythm) and lungs (diffuse wheezes bilaterally and crackles throughout) and examine his impressive 4+ bilateral pitting edema.
All in all, this took about 10 minutes. He wasn’t a very talkative man – probably due to his inability to breath – and his physical exam rarely varied.
On day 4 his right hand became edematous. That was the day my attending gave me a “gold star” for teasing out that he has a history of gout. Back on the prednisone he went – just when we had finished his taper from his last COPD exacerbation.
Next I would turn to his wife and spend the next 5 minutes having an identical conversation every day. I would inform her of the changes we made and what we were hoping they would accomplish. I stressed the complexity of his situation. Heart rate vs blood pressure, lungs vs kidneys.
“We’re stuck between a rock and a hard place” I found myself saying day after day.
We had run out of options. He had failed amiodarone when he was first admitted due to prolonged sinus pauses during conversion to sinus rhythm. Our last resort was to give him a pacemaker, then we could then load him up on amidarone and he could pause away all he liked.
The only catch was that in order to get the pacemaker, cardiology required he have a life expectancy of at least 6 months. So we talked to the oncologist, who is unable to give a prognosis without the patient completing the full round of chemotherapy. Only as long as the patient remained in uncontrolled atrial fibrillation he is not stable enough to get the chemotherapy.
It was a circular argument – the man could not live without the pacemaker, but he could only get the pacemaker if he was expected to live.
Finally, an agreement was made and he was sent down to get the pacemaker.
I come in the next morning excited that he will finally be turning the corner. I take a look at his morning labs and vitals and I’m shocked – they were horrible.
I look for the op note from cardiology, and I find that he never received the pacemaker. He was unable to lay flat as they were prepping him for the procedure, so it was aborted and he was transported to the ICU in acute respiratory distress.
I take a look at his chest x-ray: it’s catastrophic.
I read the notes from the ICU doc, the nephrologist, the cardiologist. I see a note from a palliative care consult.
Over the last week I had often wondered to myself when it would finally be the time to call palliative care and talk about hospice. Something about this family was shrouded in such optimistic denial that it never seemed like a good time to bring it up. This man fully believed that he would be able to get well enough to go back to work. I think we all wanted to believe that too.
I take a deep breath, and head to the ICU.
When I enter his room, I see him laying on his back for the first time. He’s on high flow oxygen through the nasal cannula, but his breathing sounds like he’s on the ventilator. He’s unresponsive and gurgling sounds escape as he struggles for air, using his accessory muscles of respiration.
I turn to his wife:
“A lot happened yesterday.”
“Yes, it did.”
We stand in silence for a moment, watching him gasping for air.
“I was really hoping he would be able to get the pacemaker.”
She nods “me too.”
We’re silent again.
“I saw that you met with the palliative care doctor yesterday, I’m sure that was difficult.”
She turns to look at me now “I’m going to tell the doctor today that we’re ready for comfort care.”
She’s crying, and I feel the tears welling up in my own eyes.
“I am so sorry, I was really pulling for him.”
She walks towards me with arms outstretched and wraps herself around my waist.
“You woke me up every morning. Thank you for being so kind.”
This man passed away later that afternoon.
There are a lot of emotions revolving around me when I think about this experience. He was my first patient to die. I have been present at codes before and have seen patients die, but this was the first one who was mine. It’s a unique and conflicting situation, mourning for and with people you barely know.
But it’s the words of this mans wife that continue to stick with me: “Thank you for being so kind.”
I’ve never consider myself to necessarily be a “kind person.” When I say that the first thing that comes to mind is one of those girls who is all smiles and brakes for squirrels and refuses to kill spiders but transplants them outside their house instead. That’s really not me.
So what was this woman talking about?
Looking back, I can’t think of anything in particular I did that was all that kind. I didn’t bring them flowers or offer back massages. The only interaction I had with them was that 15 minutes every morning. It wasn’t anything out of the ordinary, it’s part of my job as a medical student.
But maybe the true beauty of kindness is that it doesn’t have to be anything extraordinary. It doesn’t have to take hardly anything from us. Maybe it’s not all about big sacrifices or superficial statements. What if the kindness that counts is the type that you don’t even know you are giving, but that flows from compassion and genuine concern?
And what if this kindness is really the most important thing we can give as a healthcare provider?
In the end, it wasn’t our valiant efforts, medical knowledge, grand medications or extraordinary measures that she thanked me for. It wasn’t my flawless explanations of the pathophysiology of the disease process nor my ability to diagnose gout. It wasn’t my thorough progress notes.
It was my kindness.
So if kindness is so important, why is it that while I feel confident that my clinical knowledge, reasoning and skills will fully develop over my training – I feel a terrifying ache that I may lose this kindness by the end?
So for now, I just fight to remember those words. To remind myself that no matter how poor the outcome or how helpless we are medically – we can always be kind. And perhaps, that can make the greatest difference.
**Patient identifying information and diagnoses have been changed to protect patient identity**