On my last day at Mercy Medical Center, I was happy to say goodbye, and knew I wouldn't be shedding any tears of sadness at leaving this job. It had been consistently grueling, and although I experienced some kind exchanges with the staff and patients, it had been some of the toughest work I've ever done as a surgical PA. I didn't expect a going away party or cake, only hoped for a few positive goodbyes and good wishes. What I didn't expect was to have this become an emotion filled day, as a dear patient chose to share his last breaths of life with me.
Joseph Wimble had been under my care a few times over the course of my stent here, having diabetic foot wounds that gradually advanced. We chipped away at the infected tissue one painful operation at a time, but on this admission, it wasn't just his extremities that were taking a toll; his heart was failing too. The whole surgical team was working to get him better and out of the hospital, but his body didn't seem to be cooperating. On Friday his heart started to fail, and as the pump for his system declined, so did his breathing and circulation. As the lab numbers looked worse and worse, his oxygen requirements increased, and I wondered how much more could be done to prolong his life. At that point, he and I had had some big talks. I started with asking him if he wanted heroic measures if his heart were to stop, such as CPR or intubation. He was certain, no he did not want that. From there things were less certain. Do we continue aggressive antibiotics? What about the tube feeds that have been keeping him alive since his throat cancer years ago? These were more difficult to answer. On Saturday, he and I reviewed what we'd discussed the day prior, and he asked me how long it would take for his foot to heal. It was difficult to communicate, but I had to remind him of what had become apparent. "Your foot is not going to heal, Mr. Wimble." He nodded his head when I said that, knowing it was true, and now starting to accept it. He was 83 years old, had remained strong throughout his life, despite battles with cancer, heart disease, diabetes, etc., but we were all starting to see that this might be the end of his fight. He struggled to breath as we discussed the plans for his care going forward, and I stepped over to turn up his supplemental oxygen. When I came back to his bedside, his son, Rick, stepped into the room. I saw the tear slip from his eye as he wiped it away and put a smile on his face to comfort his now dying father. I blinked back tears of my own to remain composed and professional, and continued on with the dressing changes to the foot, which had no hope of carrying this man any further on his path.
Later that afternoon, as visiting hours were coming to a close, I made another trip to the room. Now Mr. Wimble had 2 grandchildren with him as well, one who had flown from North Carolina when she found out this could be the end of Grandpa's beautiful life. The family asked that we step out to speak, and the 4 of us sat around a conference table to discuss how things would go from here. These conversations are never easy, and I have to admit, I was hardly prepared for what was happening. I'm not a palliative care specialist, have only taken a few people through this process, and although plenty of my patients have passed on, none of them have actually chosen to do it while I was present. It was also an incredibly busy Saturday afternoon at the hospital, I had a dozen other patients to take care of, and I was not expecting to have this to navigate as well. I took a few big breaths and sat down to guide this family around the ins and outs of facing the end of their loved one's life. I didn't know all the right answers, but seemed to satisfy the needs they had for guidance and management of their patriarch's last days. We made decisions together about how much treatment to continue, added medication to calm the anxiety that he had started to demonstrate, and shed a few tears together as we talked about how difficult it is to watch a loved one transition.
The next morning, the chief surgeon came with me on rounds, and as we walked to Mr. Wimble's room, I filled him in on the conversations and occurrences of the prior day. He confirmed that there was no way this man could tolerate another surgery on his foot, and we had a united front to help the patient understand his prognosis. When we arrived at Mr. Wimble's bedside, he was anxious to know what his treatment options were. The surgeon kindly and clearly explained that the treatment now is comfort care. 'Whatever we can do to keep you comfortable, is what we will do." The patient accepted this quickly, now the third conversation with the same message, and the appreciation of the son increased as he watched his father accept that the end was near. Son Rick and I returned to that conference table, and with tears running down his face, he thanked me for all I had done. I could hardly take any credit, feeling that Rick had done as much to guide the process as I had, and I realized I was learning as much from his emotional intelligence and clear communication as he was from my medical knowledge and expertise.
When people decide they are ready to transition out of this world, we never know how long that process can take. I've seen it go on for several days, with eyes closed but hearts continuing to beat, while a soul works out their final tasks, before going on to the next life. On Sunday, Mr. Wimble and I had very frank conversation about his care and how he wanted to continue, him even asking if it would be possible to go to a rehab facility in the coming week. He still had ideas of returning to life as normal, making plans for recovery. When I returned to his room less than 24 hours later, he was sedate, his breathing slightly diminished, but certainly not distressed. Rick had gone home to shower and refresh himself after spending the night at his father's bedside, so I completed the rest of my morning rounds and made plans to circle back in the afternoon to check in. At 2:55, I returned to the room, finding Rick sitting at Mr. Wimble's bedside, tears in his eyes. His expression of emotion triggered mine, and it was with complete sincerity that I thanked him for allowing me to be a part of this experience with them. He looked at the clock several times, and with his voice trembling said, "His respirations are only 4 per minute." I asked how long it had been that way, and he tearfully said, "I just got back." Mr. Wimble had lived a lifetime for his family, and even on his exit, took their needs into consideration, waiting until his son was with him to make his exit. Rick and I looked at each other, looked at this man on the bed, and watched him take his final breaths. The son knew how to navigate this, and told his father, "Dad, it's OK. You can go. Mom's waiting for you." Once he said that, there wasn't another gasp. He was gone. And I was privileged to be there through the transition.
I looked at the clock after watching his soul leave the body, knowing that it was my responsibility to call the time of death. It was 3 o'clock on the dot. I found it interesting when noting the time, not only because he left exactly on the hour, but also that I had walked in for the final 5 minutes of his life. If I'd been there 20 minutes sooner, I probably would have had to leave prior to his passing. I just as easily could have been minutes too late. This was divine timing, and a gift I was allowed to share.
There was no question that this body was empty of life force, but I followed the protocol to pronounce the death, placing my stethoscope on his hollow chest, shining a light into his unresponsive pupils. Then I excused myself from the room to filled out the death certificate and contact the morgue. After completing some necessary logistics, I returned to the room, where Rick's wife had arrived. I wasn't sure how to leave them, or how long they would want to stay with the body, but again, these people guided me more than I did them. They reminisced about his life, sharing stories of his hunting escapades, fantastic baking skills, and generosity of land, money and time. After his throat cancer, he was no longer able to eat, surviving on tube feeding for the past several years. Despite his inability to taste any of the decadences, he continued to feed the Wimble clan at every holiday. He was known for his venison goulash, featuring deer that he had hunted that season. The Christmas baking was all done by him, the specialty walnut pastries that will now be missed. He was even living with a long time friend and a late in life companion, who he cooked for 3 times a day up until this final hospital admission, never tasting a bite of any of that food, never making any complaint.
In my over 20 years in medicine, I've engaged in all sorts of environments and social situations, had many opportunities for reflection on how much relief we are really bringing to people when they are suffering. Now I'm looking towards the end of my career, watching the system decline, often questioning the value of what we do in medicine. Today gave me a reminder of some of that value. This man had been under our care for the past 6 years, at which time his previous surgeon had said there were no further options. This surgeon had given him another chance at that point, doing an operation that wasn't guaranteed success, but resulted in several more holidays, hunting seasons, and good years of living for Mr. Wimble. Being with his family, hearing the stories of the life he lived in those 6 years, gives me some satisfaction in the good we get to do here. Not every day feels this profound, and I'm grateful I was able to spend my last day at Mercy Medical Center with this reminder of why I do this.