The first time I saw Mr. Nelson I knew that he would not live long. I walked into his room with my housestaff. He was lying in bed at about 15 degrees elevation. His skin was a pasty yellow. His eyes were a bright yellow. His swollen abdomen had a huge indurated hernia looking like an extra appendage.

Mr. Nelson had consumed large amounts of alcohol in the past, and was infected with hepatitis C. He was 49 years old.

He talked slowly but coherently.

“How long do I have Doc?”

I responded, “I really can’t answer that question yet. I find it very difficult to make predictions.”

We chatted for a few minutes. I told him that I wanted the palliative care service to see him, and explained what they did. He thought that was a good idea.

Mr. Nelson had had stable cirrhosis until the previous week, when his ascites worsened. He started leaking fluid through his indurated hernia site.

Over the next few days I got to know Mr. Nelson and his live-in girl friend. The surgeons agreed to try and repair his hernia for palliation. He understood that he stood a high risk of dying during surgery. But as he told me, “Doc, my life is horrible now. Anything that might make me feel a bit more comfortable … ”

On day 5 he started doing worse. His urine output decreased and his mental status diminished. Periodically he had lucent conversations. During one of those, he told his family that he would be dying soon.

His laboratory data supported his assessment. His liver function worsened with his coagulation parameters increasing dramatically. His renal function worsened.

Meanwhile, we increased his intravenous morphine to decrease his suffering. On a Friday night, with worsening vital signs, the covering intern stopped the morphine drip.

That Saturday morning, on rounds, we went in to see Mr. Nelson for the last time. He had that look that we all learn during our training. His breathing was shallow, yet appeared uncomfortable.

We gathered his girlfriend and his two daughters.

I told them that the end was imminent. I expected that he would live no more than 48 hours, and probably much less.

Given his lack of mental status, I asked them if they preferred us giving him morphine again, knowing that he might not live as many hours, but he would suffer less (and the family would suffer less). We discussed the pros and cons, and decided to restart the morphine.

He died 6 hours later. The family had made their peace and understood that it would happen soon.

Patients die on the medical wards. He died from his disease, comfortable and supported. We had nothing to offer him other than comfort. We did that and I believe did a good job of providing him as much dignity as one can muster in a hospital room.

I write this post with the full understanding that he was a human being loved by his family. They are suffering from his loss.

As physicians we suffer with each loss. We try to make sense of what happens.

Often we do everything right, and the patient still dies. I believe that to be the case for Mr. Nelson. Still, we mourn his passing and the loss that his family suffered.

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I have changed names and a few facts for the purposes of confidentiality. The essence of the story is true.

Related posts:

1. A guest post on “expertise”
2. Patients leaving primary care physicians who eschew the hospital
3. Family medicine vs internal medicine
4. Geography payment wars
5. The barrier – echoing my mantra

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