Bad Things Come in Threes

They say “bad things come in threes.” During my first two years of medical school, my wife and I lost three of our grandparents. During the second year of my fellowship, we lost two grandparents about a month apart. They both were in their 90s, and died the way I think most 90 year olds should die..on hospice.

My Grandmother, whom I called “Bubbie,” was as energetic as they come. In fact, there were times when I think I had trouble keeping up with her. She spent her 90th birthday recovering from a triple bypass and a mitral valve replacement. She recovered extremely well and paid out-of-pocket to go to cardiac rehab three times weekly until a few months before her death, just because she wanted something to keep her busy. The surgeon did not correct her coexisting aortic stenosis at the time of her surgery because of her age and comorbidities. By the age of 97 she was becoming progressively dyspneic. I lived across the country and so never met Bubbie's cardiologist, yet I respect him immensely because of the time he spent discussing end-of-life care with her. On her last visit, he told Bubbie that he would be happy to continue to see her, although there was nothing more that he could do for her worsening aortic stenosis and progressive shortness of breath.

My Mom called me one morning to tell me that Bubbie was significantly more short of breath, and she needed help with everything, even her ADLs. However, she did not want to go to the doctor, and definitely wanted to stay clear of the hospital. I told my Mom it was time for hospice. Initially, my Mom did not understand. “It's not like she has cancer,” “She is not that bad,” “What can they do for her?” were some of the things she uttered. I explained to my Mom that Bubbie was ready to go when her time came, she wished to remain at home surrounded by her family, and that she needed the services and support available through hospice to allow for both her and my Mother to be comfortable with the process. Bubbie made it three more months. During those three months, the closest she came to seeing a doctor was when I visited. She spent her time doing what she loved most, visiting with family and friends, playing the occasional card game, and watching her favorite reality TV shows. I had the opportunity to visit her twice, and my daughter was able to see her “Gigi” (short for Great-grandmother) one final time. One evening Bubbie peacefully passed away with my Mom by her side.

Just over a month later, my Grandpa, whom I called “Zadie,” passed away. He was a World War II veteran, and not only survived his tour of Europe as a B17 ball-turret gunner, but survived lymphoma in his 70s, as well as bipolar disorder. He continued to golf, swim, and play tennis until around the time of his 90th birthday when his health began to deteriorate. His doctors really couldn't pinpoint the etiology of his decline. He had developed congestive heart failure and atrial fibrillation, but even when he was “medically optimized,” he progressively spent more time sleeping, and less time talking and eating. My Grandma took care of him until she couldn't any longer, at which point he went to a nursing home. Not long after, he developed worsening dyspnea. My Mom mentioned to one of his caregivers that he should be on hospice. His caregiver responded with a look of disbelief: “Not yet.” That night he developed respiratory distress and was taken to the local hospital.

He was admitted with a heart failure exacerbation. Yes, he did have a treatable condition, nothing that some diuretics wouldn't fix, at least for the time being. Yet my parents and I realized that he had nothing left to live for. He spent his days and nights in a wheelchair, sleeping, staring out into the horizon; this would be the first of many trips to the hospital. The next day he was transferred to a hospice facility where he passed away comfortably within 24 hours; he was 92.

I remember as an intern not understanding why my attendings recommended hospice for patients without cancer, who had what I considered to be “treatable” medical conditions. Now I know that it is not about how treatable the condition is, but about the patient's reserve and overall quality of life. All patients die, some earlier than others, and we can't control that. What we can often control is where they die. Will they die in a hospital getting chest compressions with monitors alarming, or in a quiet room surrounded by their loved ones?

In my pulmonary clinic, and my hospital's intensive care unit, I encounter tragedies on a regular basis. But for someone to die in his or her 10th decade of life, surrounded by the ones they love, is not a tragedy but something to be celebrated. I just pray that this time, bad things only come in twos.