Comfort care

"Well, she does have years of experience on me..." I thought, when I heard my attending had noticed a subtle difference on the abdominal exam and ordered a KUB (Abdominal x-ray, showing the Kidneys, Ureters, and Bladder) which showed free air under the diaphragm. In this elderly lady with severe constipation--otherwise known as fecal impaction--air under the diaphragm pointed to an unavoidable conclusion: her vicera had perforated.

That morning, I had perceived a bit more abdominal fullness than before, but it was difficult to determine how tender she was when she'd cry out just because of my "cold" hands! The afternoon KUB results, however, made the course unambiguous. A younger person could tolerate a large, challenging operation, but could a frail 95-year old survive it? And if she did, would she ever get out of the ICU? The surgeon confirmed our doubts--he wouldn't operate.

After a discussion with the patient's family, my attending put the patient on "comfort care." Antibiotics were stopped. (Though started for a simple cellulitis, these antibiotics were powerless in the face of stool spilling out into the peritoneal cavity.) Vital sign checks were discontinued. I.V. fluids were no longer needed. We began titrating morphine into this lady's veins as her family stood tearfully by. Our goal was not cure or even prolonging her life; we were simply trying to keep her comfortable.

As I related from my last call night, I was again overwhelmed by the privilege it is to walk with patients to death's door. And it's truly a precious opportunity to be a healer to the patient's family. We talked of her long, full life, and her daughter told me she wished I could have known her mother "as she was." The daughter had hope: she knew where her mother was going. At some point, I offered to pray with the family, and they practically embraced me! A long night was ahead of them...