Making Final Days Peaceful

Sometimes a person’s life ends quietly, sometimes amid a battery of high-tech machinery and a bustling hospital staff. These days, the choice is often beyond the control of patient or family. But not always.

I was reminded of these facts when I played an unwitting role in the final chapter of a person I had never met.

At a holiday party last year, a woman with a dark-haired bob approached me with a warm greeting. “Thank you so much for your advice on the phone,” she said. “My mother died peacefully a few days later.”

Initially, I didn’t make the connection. Then I realized she was a casual acquaintance who had called me weeks earlier in desperation. After 15 months of spiraling downward, her mother, 89, lay dying in an Orange County nursing home.

First, the mother had fallen and fractured a spinal vertebra, which limited her ability to walk. Over time, frailty and dementia added to her plight. The last straw was a painful, blistering skin disease called pemphigus for which she received periodic rounds of high-dose cortisone medication. The cortisone, in turn, had triggered high blood pressure and possibly heart disease. As a result of all these miseries, the patient had gone from living in her own house to assisted living to hospital to skilled nursing facility and back again, her daughter explained to me.

At the time of the call, her mother’s mouth, eyelids and skin were actually healing, but her general status had taken a sudden, ominous turn for the worse. Meanwhile, a conflict had arisen. The consulting dermatologist was arguing for an aggressive rescue mission, including transfer to a major hospital.

The primary care physician, on the other hand, seemed content to focus on mere comfort measures rather than one more temporary victory in a losing war.

By now, the patient could no longer voice her own wishes. However, her views on end-of-life matters were well-known. Ten years earlier, according to her daughter, she had even spelled them out in a letter. Although she loved life, she wanted no heroic efforts if her medical prospects were poor.

By the time I sorted through these facts with my caller, I realized I was in a delicate position. Strictly speaking, I was not being asked for a professional opinion, but some fragment of insight from years of working as a medical professional.

Looking back, there are many ways I could have responded. I could have had the woman’s mother transferred to the hospital where I work. I could have found another doctor in Orange County to examine the patient. Or I could have simply bowed out, which, honestly, was the most tempting option.

Instead, I asked myself: What did my caller really need? I decided she needed help understanding and working with her mother’s current doctors.

Impulsively, I blurted out something like this: “You know, doctors are people too. It’s very common for specialists to offer aggressive treatment. That’s what will probably happen if she goes to the hospital. That doesn’t mean it’s the right thing for your mother. It’s OK to question. It’s OK to decline or stop treatments, if that’s what you think she would want.”

I guess it was the right thing to say. As I later learned, my words furthered communication between the family and the primary care doctor.

Together they chose to keep the patient in the nursing home, withhold further treatment except for pain medication and let nature take its course.

But when that holiday party conversation forced me to examine the outcome of my uncensored remarks, I confess it gave me pause.

After all, I have often stood on the other side of the fence, engaged in long battles (along with other hospital specialists) to preserve elderly, debilitated patients. I needed some reassurance that my instinct that day had been right.

“Did you have any regrets afterward?” I asked her daughter.

“No, no regrets at all,” she replied.

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Claire Panosian Dunavan is a physician in Los Angeles.