Cutting Loose.

"I'll give you 20 dollars if you cut me loose!" At 75, she was petite and spry, her legs dangling across the bed railing, her arms gesticulating wildly. Unrestrained, sassy and delirious. Just after extubation in the windowless confines of an ICU room.

She cut herself loose not long after, and died a peaceful death after she was transitioned to "comfort care."

By month 2 of your intern year you learn how to make this transition quite deftly. You explain, tactfully, but not excluding some of the vivid details, of the process of resuscitating what is, for all intents and purposes, a dead body. You explain, sagely, that it may cause more suffering and sometimes cause irreversible injuries to the brain. You give families a choice that they rarely ever want to make. Some patients and families are ready. Others aren't.

You realize that paternalism is not always a bad thing, and "autonomy" is not always a good thing, especially when you ask families to speak "autonomously" on behalf of the patient. And you are constantly striving to redefine those words and negotiate your place between them.

Since month 2, you have had strong opinions about this matter. The answer is easy when your patient already suffers from severe dementia, has widespread metastatic lung cancer and is 95 years old. Medical futility.

Primum non nocere. First do no harm.

For the first time in a while, I found it difficult to cut a patient loose, in spite of his persistence. He was in his mid 70s, a jovial Creole gentleman with a really bad heart. His heart failure specialist had determined that he was not a candidate for advanced therapies and thus he was on my service. My goal was to send him home with palliative therapies. And so we tried to "optimize" his heart failure regimen, with diuretics and medications to help his heart pump, but each change seemed to make him feel worse. And I could not let go of the fact that we were doing more harm than good, and all I wanted to do was change things back to "the way they were." Before he started to feel worse. Before we threw on the lasix drip and the dobutamine drip and the milrinone drip and everything.

We spent two weeks chasing numbers. Creatinine to measure his kidney function. Jugular venous pressure to measure his intravascular volume. "Ins and Outs"- how much fluids he took in, how much was he urinating out.

But he had his own ideas. His idea of "the way things were" were vastly different from my own. In my version, he was the jolly old man in a chair, watching Haiti on CNN and comfortably eating his cardiac/renal diet of bland eggs without seasoning and home fries. In his version, he was home, walking around, running his errands with a little bit of shortness of breath now and then. And when we made it clear that he was not going to be able to be that person again, he wanted out.

He kept telling me that he was feeling weaker and weaker. And all I could think about was the fact that we were doing something to him. Like most patients with severe heart failure, it is impossible to find that balance between getting fluid off with diuretics to improve the dynamics of the heart's "pump" and making him pee so much that he becomes dehydrated. If you don't find that balance, the kidneys will fail. Assessing a patient's "volume status" by virtue of the clinical exam can be even more challenging in someone whose has pulmonary artery hypertension from other causes- in his case scleroderma.

In the last 48 hours, I became fixated on the idea that he had digoxin toxicity from his now worsening kidney failure. This can cause obscure neurologic symptoms, GI disturbances, heart arrhythmias and malaise.

But so can heart failure.

He finally said to me, "Doc, I am ready." And I finally listened. He told me that I "had done a good job." And, for the first time in a long time, I wept. Right there in front of my team, in the hospital.

Cutting loose.

"I am glad in the end we could be friends." This was the last thing he said to me today. Whether I will see him tomorrow remains uncertain.

Most of the time, transitioning someone to a more comfortable death can be one of the most powerful and gratifying experiences a physician can have. Those were some of the most profound experiences I had as an intern.

I am at a loss to explain why this was so hard for me now, 6 months shy of the end of residency.

****************

She was 81, chattering away at the nurses' station in Cantonese, looking splendid in her leopard print pajamas and Adidas running shoes. She refused to go back to her room because she did not like her male "sitter." The alternative euphemism, coined at the county hospital, for these individuals who watch over our cognitively impaired patients is "coach."

At the VA, the double doors to the lowest acuity floor have the following sign: "Wandering Patients: Please leave doors closed."

I hope that one day, when I am a little old gray haired lady with dementia that I too will have the wherewithal to sport leopard print pajamas, and more importantly, running shoes. Lest I ever feel the urge to cut loose.