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Laughing in the Face of Death

— Only the rare patient has a sense of humor at the end of life

MedpageToday
A portrait of a senior man in a hospital bed.

It may be morbid to have a favorite death, but the story of my patient Don has been my favorite to date.

"He wants to hear a song," Don's family said when I walked in the room. For a minute, I froze -- surely, they were not expecting me to sing? Fortunately, one of his daughters pulled up YouTube on her phone and "Another One Bites the Dust" began playing. His wife told me they played the same song at their wedding 40 years ago.

Just yesterday, we had been trying to decide what the next treatment options were for this patient. He needed to get fluid off, but his kidneys were not responding to all of the diuretic medicines we were pushing. We tried dialysis, but his blood pressure dropped too low when they removed fluid with the machine. His heart had converted into a rhythm called atrial fibrillation, which it never had before. It could have been in response to the stress of dialysis or his worsening heart function, but we needed to act to protect him from this abnormal rhythm.

We were on a last-ditch effort to transfer Don to the intensive care unit where he could receive a gentler form of dialysis called continuous renal replacement therapy (CRRT). Before I left, I spoke with him and his family about the unfortunate path we were heading down. He had decided long ago that he did not want CPR, but the discussion around the many invasive medical procedures we offer is still nuanced. The last thing you want to happen overnight is being unable to contact family or speak with the patient about their wishes. At the same time, we still hope that the interventions we offer are enough to help the patient return to health. If we are successful in helping the patient recover, did we put the patient and family through unnecessary emotional distress of discussing all the worst-case-scenario options?

In this particular situation, we spent a long time discussing intubation if Don's breathing were to worsen. We had a few steps to go through before we reached that point, but I was worried he could easily head down the road of respiratory distress. His family was not sure at that point, but Don had previously said he did not want intubation, and now that it was a potential reality, my patient and his family had changed their minds -- but they were still not 100% sure. Over the course of the night, the worst-case scenario I had posited earlier happened: the dialysis was not working fast enough to make up for how poorly his heart was functioning. The last possible intervention we had to offer was not enough. His breathing was okay, but the overnight team ended up needing to start medications to help with his heart squeeze (inotropes) and with his blood pressure (vasopressors). His family was able to come to his bedside where I found them the following morning.

Our discussion that morning centered on where we go from here. Don's heart was so weak that we were doing everything we could to sustain him, though it was only to buy some time. He and his family ultimately decided to change the plan of care to comfort later that morning, and during the last few hours of his life, he was kept comfortable and surrounded by the people who loved him most. As he so eloquently put it, "What more could I want? Maybe some coffee."

While I am no stranger to end of life situations, particularly in the hospital, I am always struck by the patients who face death head on. We usually have discussions with family members because the patient cannot speak for themselves, but it is rare to have the patient involved. It is even rarer for the patient to face it with an unrelenting sense of humor.

During our morning discussion, I asked Don if there was anything else I could do to help make him comfortable. He drily replied, "bourbon, rocks." While I could not deliver on the bourbon, I told him I could get him coffee from the nursing station, but I assured him it would not be good coffee. He took me up on my offer and continued to joke throughout the day that I had only half delivered on my promise. I also had the incredible privilege of sharing space with his family as they recalled their favorite moments together over the years and he corrected his wife's details about where they were and how they met. He told his family that he would be gone by 10am, but he stayed with us well into the afternoon before I was called to pronounce him.

So, why is this my favorite patient death? While we cannot change the body's ultimate fate, we have the privilege to guide our patients and families through this transition. In medicine, we tend to focus on ideal outcomes -- patients going home with their families and returning to what they love -- but often this is not a realistic expectation. While there is no way to capture the relationships we have built with our patients and their families for billing, I would argue that there is just as much, if not more value in being able to look death in the face and still laugh.

is an internal medicine/geriatrics PGY-2 at Medical College of Wisconsin.