he was old. not so much in years, but old. his body had born the brunt of a full life. there was not much left. so when i saw him the first time with a rock hard abdomen and free air in the peritoneum i knew it would be a long shot.
in discussion with the patient and the family, we went ahead and took him to theater. if he had any chance whatsoever, it would include surgery. he did, however state his desire not to be kept on 'life support'. we informed him that he would be on a ventilator at least for some time post operatively. he accepted that and we went ahead.
the operation rendered a few surprises, but we got through it and delivered the patient to icu, intubated and on a ventilator. amazingly enough he did well and, was extubated on day two. the family (and surgeon) were elated.
then on day four he started slowly but surely deteriorating. he told us he was tired of life and just wanted to die. he also said he didn't want the tube down his throat again. then he slipped beneath the waters of consciousness. i was called.
he clearly wasn't getting enough gas exchange and needed to be intubated and ventilated. however i was more and more convinced he was destined to die no matter what we did. we could prolong his life but he would never leave icu. i called the family.
i laid out the medical facts and told them they must decide if we should be active or leave him to die. they discussed it. it was not an easy decision for them and i could see them struggling with the concept of just letting him go while he was still alive. medical facts weren't good enough. i told them what i thought.
i firstly explained that to intubate held little guarantee of ultimate survival in this case. i then went on to say that it was probably better to die without a tube than with a tube. also to delay the inevitable would prolong his suffering. i then reminded them of something they all knew, i.e. that he had said he didn't want to be kept alive by a ventilator and maybe it was time to respect his dying wishes. they reluctantly agreed. i left the family, together maybe for the last time.
maybe i swayed them. maybe i influenced them to decide what i felt was best rather that just giving them the facts and allowing them to decide themselves. but sometimes medicine is not about facts. we are working with people and relationships and human interactions as well as just physiological systems and these things will always play a role. i was content with my actions and went home.
but what they did not see, what no one saw, was the moment just after i spoke to them when i moved off alone and thought about that day so long ago. the day i held my grandmother's hand in another icu in another city as she breathed her last breath. she too had also declined intubation. she too was given the choice of a death with dignity. i cried.