Wednesday, April 23, 2008


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.


Sid Schwab said...

These are the most difficult things... I was there when my father died, having had to be the medical mediator for the family. We agree it was time to extubate. And we sat there with him after.

I think there are more "errors" (if that's the word) made on the side of prolonging agony.

rlbates said...

So difficult to be sure of the "right" thing, but I agree with you and Dr Sid.

Greg P said...

In many cases I find that "laying out the facts" ends up being opening up my own eyes and ears, so I can not only give information but also ask for it, I can listen for it when it is there without asking, I can see it in the faces, the body language, hear it in the cadence of the speech, the clutch in the throat...

Jayne said...

Bongi, this really hit home with me, as my motherinlaw died a couple of weeks ago & we had to request that there was no DNR. I'm currently living in an Islamic country & it's against Islam to 'end' life, but thankfully, our spoken instruction was accepted by the doctors & nursing staff. Both my husband & myself knew it was what she wanted - she'd refused chemo & knew that cancer had got the better of her. I'd nursed her at home until I could do no more. Since the 8th of April, I have mentally beat myself up & repeated "I could've done more" even though I know full well that I honestly couldn't. I am more than grateful that doctors do tell the family exactly what to expect & I agree, it really is a horrible decision to make, but ultimately, it is the right decision.

*hug* for dokotela bongi :-)

Anonymous said...

Pragtig geskryf.

Bongi said...


Jeffrey said...

wow. i kind of relish the chance to break the news one day, yet i fear of the prospect of facing the soon-to-be bereaved family. certainly one of those heart-wrenching moments in medicine. never easy. excellent writing and description. you should write a book some day. i'll definitely buy it

Anonymous said...

Where and when there is no cure, there is always and forever comfort. The most difficult part is that of being present and being therapeutic by virtue of your professional and genuine presence, regardless of prognosis.

But too, consider that death is a part of the normal cycle, and it is not failure or an admission of helplessness. (I think you already know that on a fundamental level, as evidenced by your genuine compassion and concern.) Thanks for writing this post.