Abstract
T
When I arrive at my first moonlighting shift on Saturday morning, a bearded, graying volunteer in a Hawaiian shirt greets me in the hallway strumming “Hey Jude” on his acoustic guitar. He shepherds me to meet the head nurse. Carefully applied eyeliner makes her look younger than her graying temples. She introduces herself and hands me a list of my patients for the weekend.
“If you need anything, doc, you have my number,” she exhales before returning to her patients, leaving me in the hallway with the volunteer. Not knowing what else to do, I scan the list. I am charged with 24 patients, each in various stages of decline. “What have I gotten myself into?” I think, as I flip through the pages. A room number, the patient's diagnoses, and a few lines of text accompany the names.
214A. Mrs. L, 85: Nonsmall cell lung cancer, mets to the brain and lung. Actively dying. Comfy.
214B. Mrs. E, 79: Dementia. Last BM Tuesday.
214C. Mrs. R, 40: Rectal cancer, metastasis to the liver and lung.
I fold the list in half, put it in my pocket, and squirt some hand sanitizer on my palms, entering room 214. The hospice, housed in a converted office building, has a variety of shared patient rooms, created by necessity in the repurposing of the space. In 214, four patient beds punctuate the walls, each separated by heavy, white curtains. Miniature televisions hover over the patients, suspended like cranes from the ceiling on metallic arms. I stiffen when I realize I am not sure which of the four women is 214A.
“I don't remember this from the orientation. Should I call the nurse?” I think, my face flushing, my eyes darting around the room. “No, don't call. There must be a system for this. You can figure it out.” I tiptoe up to the first sleeping patient's bed. Relieved, I find an ID bracelet on her wrist and am able to match the name.
Patient 214A: Mrs. L, 85: Nonsmall cell lung cancer, mets to the brain and lung. Her arthritic knuckles curl under her chin. The slope of her body barely registers under a lavender bedspread—the wool is pilled but underneath there are careful, handmade stitches. The room smells both clean and sour, like a mix of Lysol and the eggs left uneaten at a neighboring patient's bedside.
“Mrs. L?” I shake her shoulder gently. “I'm Dr. Segar. How are you?”
No response. “Hmm.” I ask myself, “Is this cause for concern? Does she talk? How actively is she dying?” I lay my stethoscope on her heart and lungs. Her heart thumps and whooshes. Her chest rises and falls. I press on her belly. She does not grimace or stir. By force of habit I untuck the sheets around her ankles and look for edema. Her skin feels cool, contracted, and dry.
On her bedside table sits a photograph of a heavier, smiling, gray-haired woman in a sweatshirt with her arms around two little kids. Is this Mrs. L and her grandchildren? She is expressionless and unrecognizable now.
“Mrs. L?” I call again. Again this elicits no response. I look around the room. One of the aides is cleaning up the patient in the bed across the hall. A nurse administers morning meds. No one seems concerned. After three years of residency, where walking in on an unresponsive patient is generally cause for concern, I breathe deeply, trying to slow my quickening pulse. I check my paper again for more information. But that's all there is: Mrs. L, actively dying. Comfy. I squash the instinct to leap into action and decide instead to move to the next patient, jotting down, Unresponsive—murmur, right upper sternal border, next to her name.
My rounds continue like this:
(1) Read the notes. (2) Squirt the hand sanitizer. (3) Greet the patient. (4) Examine the patient. (5) Make notes on the list.
Across the hall, in a private room, my next patient is propped up in an awkward, semiseated position. His bent knees form two knobby hilltops under his blankets. Seawater-infused sunshine illuminates his comforter. I look up through his window. Across the cove a line of gray and white houses stare back at me, their shutters already fastened for the winter. My patient rests with his eyes closed, impervious to the view, his face translucent, veiny, and pale. I check his quick notes: Multiple myeloma, hypercalcemia. Increased morphine dose yesterday.
“Hi. Mr. S?” I say, laying a hand cautiously on his shoulder. I startle when his eyes pop open, the left one bulging asymmetrically away from the socket. “Good morning,” he says in a refined British accent.
Dropped into the end of their lives, I wake—or in some cases am unable to wake—my 24 patients. A sticky film of sanitizer accumulates on my hands. Back in the charting room, the no-nonsense nurses put in their requests for orders.
“Mrs. R looks worse today. I already spoke with the family,” says the head nurse. “I think we should increase her Dilaudid.” I agree, and write for a dose increase. Another nurse asks me to order Ativan, her placid tone becoming ever so slightly annoyed when she highlights where I have failed to initial my name in the chart. Dutifully, I pen N.S. in black ink at the bottom lefthand corner.
I chose to spend this weekend working at the hospice because I normally love this work. Attention to symptoms, relationships, teamwork, and patient preference require the doctor to slow down, get to know the person, and think. I usually look forward to forming relationships with patients and families; but here in this strange, temporary role, I am unable to do so.
I try to match my demeanor to the idyllic view and the soothing tone of the nurse's voices, but underneath I am desperately trying to remember the patients' names, their diagnoses, and whether they are one of the minimally responsive ones from my list. Please don't ask me for details, I think, as I sweat and try to answer the families' questions. I do not have time to slow down. I barely have time to think.
In 48 hours at the hospice, I sign four death certificates, speak with 20 family members, write countless orders, and document 48 handwritten notes in the chart. At the end of the weekend I survey my work. Ink smudges the corners of my list. Marginalia on each patient clutter the text. A deep crease down the center blurs the words where I have folded the pages to fit in the pocket of my white coat. The second page falls away from the first, ripped from the staple at the top left corner after one too many turns. Before leaving I add a few lines of text to update the team with the events of the weekend, relieved to think of the cavalry returning on Monday morning—doctors, nurse practitioners, pharmacists, chaplains, counselors, social workers, even art therapists—back to work after their time away.
214A. Mrs. L, 85: Nonsmall cell lung cancer, mets to the brain and lung. Actively dying. Comfy. No changes. Remains comfortable. Updated family.
214B. Mrs. E, 79: Dementia. Last BM Tuesday. Had BM Sunday.
214C. Mrs. R, 40: Rectal cancer, metastasis to the liver and lung. Complaining of worsening pain Saturday. Increased Dilaudid dose. Declining.
Fatigue, patient volume, and lack of continuity threaten to strip our patients down to these few lines of text. This whittling away exists in the hospital, where we often pass patients from one provider to the next, in clinic where 15 minute appointments demand we interrupt—but it seems particularly unfair at the end of life, where our patients' stories are at their longest and, hopefully, their most complete. Ask me now for details about the patients who died this weekend? I would like to tell you something, anything about their lives—the cat's name, what wars they fought in, what cereal they like to eat for breakfast, how their children remember them. I want to tell you these stories. For my future patients, I will try. But for these patients? For this weekend? I bow my head. I cannot even tell you their names.