David J. Rhine, MD
From the Department of Emergency Medicine, Kelowna General Hospital, Kelowna BC.
The notice appeared in the local paper. The obituary read: "Rogers, Jim and Carol died peacefully together as they lived, after a short illness." The poignant story of this couple and their death did not accompany the notice. I was party to the story.
When an emergency physician says he is party to the obituary, it is not often a story he wants to "shout out." Those of us who are really paranoid about our jobs often read the obituaries to see who has passed away among those we recently cared for and to take note of the surprises; then we have the Canadian Medical Protective Association on speed-dial for those deaths that were really unexpected. In my 27 years as a career emergency physician, I don't think that I have ever looked forward to reading an obituary about one of my patients (in this case 2, of my patients) and shared their story so widely. What was so different with Carol and Jim?
On the morning of a routine emergency department (ED) day shift, Jim was sent down to the ED from a medical ward. He had collapsed while visiting his wife. Coincidentally, I had admitted his 86-year-old wife one week earlier with urosepsis and multiple medical problems. She was dying, and the family had assembled to pay their last respects. Jim, her husband of more than 60 years, had been sitting by her bedside on a near-continuous basis for the previous 4 or 5 days. Carol was expected to die imminently. The family was accepting of her fate. On the morning in question, Jim had leaned in close to Carol and told her "I am going to die before you do." The adult children gathered in the room were surprised by this exchange. Carol objected and told Jim that he was talking nonsense. However, a few minutes later, Jim complained of a pain in his left flank, followed by epigastric pain. According to his son, he became pale and sweaty. Jim's son tried to help him to a nearby chair; Jim couldn't walk. His son picked him up and placed him in a wheelchair. Jim did not have the strength to sit there by himself and collapsed to the floor. Nurses were called. Jim was pale, cool and sweaty, with a low blood pressure. A Code Blue was called. The intensivist on call was nearby and assessed Jim. A bedside diagnosis of leaking abdominal aortic aneurysm (AAA) was made. The intensivist called me: "I have a 92-year-old man who has collapsed on the ward. He is hypotensive and I think he has a leaking AAA. Since he is not a patient of the hospital, will you see him?"
Jim was immediately transferred to the ED. He arrived fully alert and conversational. His BP was 70 systolic. He had a palpable, pulsatile abdominal mass that was revealed by bedside ultrasound to be a leaking AAA. Jim was immediately told of his diagnosis and the grim prognosis. He was told that surgery could be an option to save his life and the on-call vascular surgeon was summoned. The surgeon arrived promptly, agreed with the diagnosis and reviewed the option of surgical care with Jim. He remained clear-headed at all times and calmly, confidently and competently declined surgical intervention. He accepted the fact that his outcome was imminent death.
We've all asked that routine question, "is there anything else we can do for you?" Most times people respond with predictable, routine requests: "Can you phone my mother/father/significant other?" "Can you call my priest/minister/rabbi?" "Can you get me a glass of water?" "Can you give me some more pain medication?" Jim asked me to come closer. He had one last request and it was something special that I had never been asked before. "Can you admit me to the same ward as my wife, so that we can die together?" he asked.
"Of course," I answered, quietly wondering to myself how we would pull this off. Our hospital is no different than yours. We are overcrowded and underfunded. Most of our ED beds are often full of admitted patients because there is no room for them on the wards. Needless to say, we had no protocol for this specific request. I asked the nurse in charge to make it happen and within 20 minutes, the porter was at Jim's bedside to take him to his wife's side. Behind the scenes, the ward nurses had made room for Jim; admitting agreed to forgo their usual admitting protocol until Jim was reunited with his wife; the porter made himself immediately available; and Jim got his wish.
Jim left the ED. Our day continued: the usual chaos, routine complaints and regular customers. My involvement with Jim and his family haunted me that day. I scanned the paper daily in the following week looking for his obituary. It appeared 5 days later—"Rogers, Carol and Jim died peacefully together as they lived, after a short illness"—not nearly enough of the story. I had to find out what happened after the ED.
Jim was admitted to the same room as his wife. Carol had died while Jim was in the ED. Jim didn't get that part of the story right. Jim was semiconscious when he arrived in the room. He wanted to hold Carol and lay with her as he died. He was placed in the same bed and held his wife of 60 plus years as he lapsed into unconsciousness. His family was gathered at the bedside. They were happy. Happy for both their parents. Happy in their death. I know Carol and Jim were happy in each others arms. Jim died 12 hours later.
I shared their happiness. I had a sense of peace, fulfillment and accomplishment seldom felt in other patient encounters. The irony of this is that it was announced in an obituary, not a thank-you card or letter. I felt that I had shared in a magical, spiritual God-created moment with Carol and Jim. I felt diminished and insignificant. I reflected on our Creator, his plan for our lives and the role we as healthcare providers sometimes play in this plan. I was reminded that we are indeed privileged to care for people in their time of need, to touch them physically and emotionally. Jim and Carol touched me back.
Thank you for this gift. It will help me as a physician and as a person. Rest in peace, Carol and Jim.
Dr. David J. Rhine, c/o KGH, Department of Emergency Medicine, 2268 Pandosy St, Kelowna BC V1T 5L2; firstname.lastname@example.org