This edition of the Physician Grind Narratives is part two of a two-part series where Dr. Tetwiler shares his experiences while caring for a patient with terminal cancer. Part one can be found at https://www.blog.numose.com/physician/madness
She waved to me weeks later. I hadn’t really known whom I was waving back to, and felt a pang of guilt when I realized. I had been leaving the outpatient surgery clinic where I had spent the afternoon looking at healing wounds, removing staples, and burning away overgrown scar tissue. Bursting out the door, I had smiled and waved at the person in a large sweatshirt with the hood pulled up as they had given a wave and shouted, “That’s the doctor” as we passed. I continued to walk on, and when I realized and looked back I saw the sweat-shirted figure limping on her crutches, with a supportive young woman at her side, disappear into the clinic door. I marveled at how she had made it out, living in the world, despite everything. The moment made me pause. In the hospital I had begun to feel like a cog in a great machine, something necessary to turn the wheels, but replaceable and unknown. She had recognized me. I was a memory she had kept. I felt hopeful.
…
A month later her named popped up in the emergency room. During a moment of peace, my senior resident in the medical intensive care unit had pulled up the list of patients in the emergency room. He wanted to see what would be coming to us over the course of the evening, which patients the emergency medicine doctors might think needed the highest level of care in the hospital. I recognized her name immediately. Then I saw that she had been brought in for vomiting blood. My stomach tightened. I told my senior I thought this one would be coming to us. I stole the moment of peace to visit the emergency room. They had taken her directly to the trauma bay, the bigger rooms in the emergency department where the sickest patients were brought. They had sat her up in the bed, and were beginning to put in her IV lines, with blood already hanging from the IV poles. I walked up to her and said hello. She looked pale and fatigued to the point of confusion. Her eyes lit up when she saw me though, and she smiled. All of her teeth were tinged with blood.
…
In the emergency department, the CT scanner had produced pictures that showed the cancer in her liver was bleeding, and the new metastases it found in her brain were bleeding as well. She was dying. She was only aware enough to talk once in a while during the few days since she had been admitted to the intensive care unit. However, she was increasingly too tired, and almost always too confused to have clear conversations. So now, after every service had been consulted, and there was absolutely nothing to be done, I needed to speak with her family.
I knew she was going to deteriorate. That her blood pressure would fall, her breathing would begin to fail, and that her heart would stop. At the inevitable end, the human body almost always plays out the final act in the most timeless way. Yet I knew what that meant for this woman in the hospital. Despite the fact that she was dying, that nothing could be done, she was still listed as full code. Full code meant that as the body begins to stop, the medical team would do everything it could to keep the machinery running. A nurse or doctor would push on her chest quickly, repeatedly, with enough force to pump blood from her heart to the rest of her body. All of her ribs would break. Medication would be given to keep the heart squeezing whether it wanted to or not. Electricity would course through her body to reset her heart. A tube would be placed down her throat and a machine would breath for her, after which she would likely never breath by herself again. When all was said and done she would likely still be alive, and despite the brutal, aggressive, efficiency of the full code, she would still continue to die. I stood at the entrance of her room and watched her family sit at her bedside. A brother, a sister, and an older man that I had yet to meet. I watched as she reached forward with her right arm and swatted her brother’s hat, a playful gesture that exhausted her remaining energy. She closed her eyes. I stepped forward.
I asked the family to step outside. I looked at the sister and confirmed she was the patient’s legal decision-maker. I realized she was younger than her sister. My age. The way she took a breath, set her shoulders, squared her jaw, I realized she was doing her best to step up to the heavy responsibility that she felt the full weight of. I took a breath. I asked them what they knew about what was going on. The sister knew everything, the brother knew the general details, and the old man kept quiet, holding his hands and looking to the sister. I told them the truth, as clearly as I could. That the little bits of cancer were bleeding, that none of the teams of doctors felt that there was anything left to be done, and that she was dying. Then I waited, giving them all the time I could. Letting the information process.
The sister spoke firmly, and looked me right in the eye. She wanted to know what came next. So I told her what I thought would happen, and about the code. I tried to weave in honesty about the roughness of a code while trying not to influence her decision. I told the sister that everyone in life heads toward the same destination, and that she was on her way there. I told the family that the medical team could hold her from going. We could keep her here with us. But only if she wanted us to. And that since she couldn’t tell us herself, that they would need to decide what they thought she would want. What her wishes might be. However, I emphasized the oldest truth to the sister, that eventually she was going to go, and that I could not change the things that were taking her there. I told them there was no guilt in letting her go, that they were not pushing her towards death, only helping to communicate her wishes, and whether she would want us to let her go. I told them about the alternative. If they decided against the code, that I would de everything in my power to provide her comfort, to make sure that she wouldn’t suffer.
The sister’s voice was angry. Not angry at me. Just sadness and frustration wound tightly into responsibility. The lost lifetime of her sister weighing upon her. She had more questions. About hospice, about palliative care, about what the next few days would be like. I did my best to answer. The brother was quietly pacing, and his shallow, controlled breaths must have been helping him to hold back tears. The old man was quiet at the sister’s side. The sister told me that they had tried to talk about her wishes, but that she had never wanted to talk about the end. She had been completely healthy only a few months ago. She was young. I understood, and I can’t imagine how painful this was. I gave her time. I could see in her face she knew what she had decided. I gave her time. I answered her questions. Then, with a wooden voice, she told me that her sister would not want the code. She asked me what she needed to do to make it happen. I explained that she already had, that I would set it in motion, and make the patient’s wishes known. The brother walked quietly back into the room. The sister followed him. The quiet old man reached out to shake my hand, and told me in a soft voice that he was her father. He thanked me and walked slowly back into the room.
I had never had that conversation before. Never changed the course of a person’s life, and the lives of their family, in that way. I felt to my core that this was the right thing to do, but felt at odds with every survival instinct that I was born with and every desire I had as a young doctor to save lives. My pager went off, another patient had passed. I went to the room, and pronounced the patient dead. The nurse handed me the paperwork I would need to fill out about the two deaths that had occurred over the past hour. In that moment I felt an odd tightness throughout my body, with a gasping emptiness in my center, and felt like I was watching myself from a distance. I left the intensive care unit. I went outside. I looked at the stars, and I took a deep breath. Then I cried. Afterwards, I went back inside and got to work.
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Keep Scrolling down for Dr. Tetweiler’s Bio
Michael Tetwiler, MD
Michael Tetwiler grew up in a small town in Kansas. After completing his undergraduate studies in English Literature, he pursued his medical degree at the University of Kansas. During medical school, he was awarded a Fulbright Research grant that analyzed clean water initiatives in the Peruvian Amazon. His work in his medical school's free clinic led him to pursue an MPH in Health Management at the Harvard T. H. Chan School of Public Health. These experiences led him to a residency in Emergency Medicine at Harbor UCLA where his work focuses on helping underserved spanish speaking communities and initiatives for resident wellness.