One of the most important, yet most difficult and most mysterious tasks we face as physicians is helping patients and their families approach an impending death. No matter how much practice I have had carrying out this role, it still takes every ounce of emotional and professional reserve I possess. And it is never routine, never the same, from one patient and family to the next. Unlike the management of hypertension or diabetes, here is no practice guideline to follow. For the physician, it takes equal measures of empathy, sympathy, and objectivity, leavened with ample doses of wisdom and intuition.
When Mrs. Snead had to face the reality of her husband’s imminent demise recently, it was my turn to help. Mrs. Snead had her own unique challenges. She and her husband had been married 35 years, and it was the second marriage for each of them. She was 75 years old, while Mr. Snead was fast approaching 90. The three of us met for the first time in the ER on a sunny late summer Sunday afternoon. It was immediately apparent that Mr. Snead would not reach his next milestone birthday. He was in acute rhabdomyolysis (his muscles were breaking down). His electrolytes were seriously out of balance. His kidneys appeared to be shutting down. Given his age, I knew I needed to lay some crepe to prepare Mrs. Snead for what was inevitably to come. But she would have none of it.
“You will do everything,” she admonished me.
We put her husband to bed snugly, deep in the womb of the hospital. I undertook some modest interventions: IV fluids, gentle sedation, and a lot of talking with Mrs. Snead each day. And each day, Mr. Snead went downhill. His labs looked worse. He became confused. There were no reversible problems I could treat to restore him to his prior state of health. He was slip-sliding down that well-known hoary slope.
Day and night, Mrs. Snead stood vigil at his bedside, fretting and fussing. She could not understand how her husband could have so quickly changed from being the robust and strapping man she had loved for four decades into the helpless, silvery person she now saw in bed. Of course, his decline had been evolving over several years, but at times like these, the human memory sees what it wants to see.
Each day, Mrs. Snead and I talked about her husband’s worsening condition. By the third hospital day, even Mrs. Snead could see his death was drawing close. Her frame of mind subtly but clearly shifted. Instead of voicing forlorn hopes that her husband might turn around, she began to ruminate on how she could possibly survive without him. How would she be able to make arrangements all by herself.
I advised Mrs. Snead to call any family members who may want to see him, because he would not last much longer, no matter what we did. “Having family around can be helpful to you at a time like this,” I added.
At that point, she became tearful and I realized I had opened an unseen wound.
“Do you have children?” I asked.
After a long pause, Mrs. Snead said, “I have a son from my first marriage, but I haven’t spoken to him in over five years.”
When I asked why, she slowly told me the following story. “I last spoke to my son on Christmas Day 1993. He wouldn’t come visit us for the holiday. You see, he did not like my husband.”
I waited for her to compose herself, then she continued.
“On that Christmas Day, he called me, and I so wanted him to come visit. But all he did was curse at me. He used the foulest language to call me one name after another. I told him I would not speak to him again until he apologized. And I haven’t heard from him since.”
“Why would he do that?” I asked.
“His father’s second wife poisoned him against me. She told him many lies about me, and he came to hate me because of what she said.”
While I had the feeling there was more to this story, she added nothing. It struck me how deep and mysterious are patients’ family relationships and personal dynamics. Families provide such intricate webs of support and deceit, love and betrayal. It is sad that some people, at their time of greatest need, feel they have a single soul to call upon for help. What her son’s stepmother have possibly said or done that would have turned him against his own mother? Was there something Mrs. Snead wasn’t saying? Was there more to this story?
“What about your husband? Does he have children?” I asked.
“Yes, he has one daughter. She lives in Detroit. But we’ve never been close. She might be coming, but I don’t know…”
We walked a few minutes longer about her husband, but she was unwilling to say anything more about her son or her stepdaughter.
If there was more to her story, I was never to learn it. Then, for the first time, Mrs. Snead said she would agree to a Do Not Resuscitate order.
On my morning rounds the following day, Mr. Snead was unresponsive. Mrs. Snead, at his bedside, was composed. We stepped outside his room and ventured down the hall to the nursing station for our daily update. I gave her the latest status report on her husband, and she quietly confirmed her mind was made up to let her husband go. She seemed more withdrawn, lonely, fragile. She knew she was facing the void, and was standing on the threshold alone.
We finished up our five-minute exchange and walked back down the hall to her husband’s room. I saw a middle-aged woman in a flowered sundress standing in the doorway of Mr. Snead’s room, her back to us. She must have come down a different hall while Mrs. Snead and I were talking. She was looking into the dark room and appeared unsure whether to enter.
I pointed to the visitor and asked Mrs. Snead if it was someone she knew.
“Why, that’s my stepdaughter Peggy. She must have come in from Detroit after all.”
The visitor, hearing her name spoken, turned, saw her father’s wife and began to approach us. I remained still while Mrs. Snead moved toward her stepdaughter. They seemed drawn to each other by unseen hands. They hugged, initially gently, then firmly, and they both began to cry.
I backed slowly away, feeling that my role was nearing its end. After a minute of hugging, sobbing, and whispering to themselves, the two women turned, arms around each other, and moved together into the darkness.
(October 1999)