The Rule With No Exceptions

It’s 1:30 am, and I’m awakened from a deep sleep by an incessant beeping to have an important conversation.

It starts with one thought in my mind.

There is no cure for death. It is the rule with no exceptions.

My 1:30 am call typically goes like this: I receive a call from the night nurse on call for our practice. These nurses are incredibly knowledgeable, and try not to wake up the physicians unless they really need to. So, when they call, I know things have gotten serious with a patient’s condition, and they are looking for help. The typical patient is a geriatric patient in a nursing home, likely with dementia, who may have been declining for some time. Often, family members have taken care of the patient for years before having to place them in a nursing home. The family may have decided, after multiple hospital and emergency department visits, to focus on comfort care. Meaning, we will do everything we can to make someone comfortable in their familiar surroundings, and, if a natural death does occur, we will not interfere to bring the person back into this world.

Family members of these patients have often watched their mothers and fathers suffer from months of pain, endure care that can be humiliating (such as wearing diapers), and forget all of their family members, one by one. In the daylight, these decisions seem easier.

“Mom would not have wanted this,” they tell me. “She would have never wanted to end up this way.”

Or, “Dad was clear in his living will that he didn’t want any heroic measures.”

But at 1:30 am, it can be a different story. After I’ve spoken to the nurse at the facility about the patient’s condition, and confirmed that the patient may be “transitioning” (meaning, passing from this world), I call and speak directly with the family member who has been tasked with making decisions for this patient. Since I am the physician on call, they typically don’t know me, and I don’t know them. But we’re about to have one of the most intimate conversations two people can have at this hour.

I explain that their loved one has had a change in condition, and make sure they are comfortable if our comfort care results in the patient dying tonight. I don’t skirt around the issue, since the alternative is to call an ambulance and send them to the hospital for evaluation. I want to make sure we are clear about the decisions we are making at this very moment. I certainly can’t say for sure if their mother or father will die this evening, while I am on call. But, given the circumstances, they might.

It is said that a person’s life flashes before their eyes while they are dying. The same can be said of the family member at this hour. Every touch, every encouraging word, every disagreement, every smile, every experience with the patient is relived in that moment of the family member making the decision. The patient has either lived a life worth living, or they haven’t.  Regardless, all of that may be gone tonight, and there’s no going back from this one.

And yet, the patient must move forward at some point, too. We discuss that even if we cheat death for their mother tonight at the hospital, the true reality of mother’s life will remain,  and we will likely be back here soon, staring down the grim reaper as he waits to take this soul to places unknown.

There is no cure for death. It is the rule with no exceptions.

In the end, many of the family members opt to continue on the path that they decided on in the daylight: continue comfort care. They get up in the middle of the night and drive to the nursing home to sit by their father’s side, soaking in each last moment of his time on earth. Others are not ready, and opt to send their mother to the hospital, hoping to prolong the event for when everyone is more ready.  They understand that day is coming, but not tonight.

When my day eventually comes – hopefully when I’m old and gray – I don’t want my kids to try to hold on for too long because the time we spent together was too short. So, once I’m off the phone, I creep silently into their rooms, hug and kiss them again, and then snuggle up to my husband for the night. Enjoying each hour as it comes, no exceptions needed.

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