Evaluating the End

“How are you doing today?” The question I ask each patient to begin a daily visit at the bedside. But what do I hope to elicit? How can I begin to understand the myriad thoughts and intricate emotions of the person before me? I am helpless. I can but listen and observe, taking in what the patient chooses to share with me. And I do so. I hear what current complaints exist; what pains, aches, and paresthesias prevent her from sleeping at night or relaxing during the day. I hear the worries and stresses; about his friends, his family, and his life. I take note of new decisions and record the old, mapping out what is believed to be the patient's desire for end-of-life care. I catch slivers of her hopes and of his vision for the end between the lines of the responses to my questions. I recognize the dismissal, the anger, the fear, the sadness, the acceptance, and the resolve in many patients. Often multiple, within the same patient.

I use my senses to observe and examine. In the elderly, time has left a considerable impression. Superficial bruises and dermatoses dotting the landscape of skin throughout the body. Wrinkles emanating from every joint and corner. Atrophied limbs the shadows of formerly robust extremities. I can see, hear, smell, and touch the signs of organ failure appearing as edema, respiratory effort, wasting, and jaundice. Sensation is decreased, motor function declining. Weak, trembling movements have replaced assertive actions. Cognition and neurologic function falling at a variable pace. This body has run its course.

My thoughts are not cohesive. A thousand messages resonate within me: positive and negative, emotional and factual, and objective and subjective. Yet I attempt to make my assessment. To come up with a reasonable conclusion. This individual has lived. She has experienced the full, predetermined timeline governing the changes to her mind and body. He was born, he thrived, he survived, and he succumbed. Such is nature. Despite the drugs we administered, the therapies we provided, the interventions we staged, and the machines we enlisted, inflicted, and inserted. This process of life is progressing to the end, fulfilling the destiny established by birth. The inevitable fate of every person. It is real. It is your fate. It is my fate. The plan and journey to that destination are the variables we have the opportunity to guide.