One of my most prized possessions is a heavy jade bracelet that I’ve never worn. It is a beautiful piece, held together with an elaborate gold clasp. It is precious because it was willed to me … by one of my patients.
Mrs. H was an elegant, aristocratic woman in her 70’s who was slowly wasting away from colon cancer. I met her initially when I was an intern on the general surgery service. She had been admitted for yet another surgery to remove yet another metastasis from abdomen. The surgery did not go well. They could not remove the entire tumor. At that point, she was so weakened by her disease and the unsuccessful treatments of the prior years that she could no longer care for herself. She had no close family and no friends to help her. She was sent to a nursing home, a rather nice nursing home, but a nursing home nonetheless.
As an OB-GYN intern, I did what was known as a rotating internship, several months each in various parts of the hospital. Therefore, I was working on the medical service when Mrs. H was admitted a few months later because of intractable nausea and vomiting. She was assigned to me and I went to her room to examine her and complete the paperwork that always accompanied a hospital admission.
I was saddened by her appearance. She was rail thin and obviously in a great deal of discomfort from the nausea. I ordered anti-nausea medication and she began to feel better. I examined her and excused myself to attend to the paper work. To my surprise, she asked me to stay a bit longer. She needed to talk to me, she said.
I sat in the chair by her bed, and much to my surprise, she took my hand.
“I want to ask you for a favor,” she said. “It’s a very big favor, though, so I will understand if you say no.”
“I’m dying,” she continued. “I know I don’t have much time left, maybe a few weeks. Please don’t send me back to the nursing home.”
I started to protest. I was as low in the medical hierarchy as could possibly be. I didn’t have the authority. I couldn’t do it.
“Please,” she whispered. “I have no family or friends who can take care of me. The nurses on the oncology floor have become my family over the last few years. They are kind to me and they make sure I am not in pain. I want to die with them. Please, can you try to help me?”
Against my better judgment, I let myself be convinced. She also extracted a promise from me that I would do whatever I could to be sure that she did not die in pain. I warned her, though, that I did not have much power. I also warned her that we might need to use a bit of deception to escape the roving eye of the dreaded UR, Utilization Review. Utilization review sent nurses through the hospital each day to look for ways to save money. One of their most important functions was to identify patients who were running up costs and transfer them out of the hospital.
Thus began my daily campaign to avoid or circumvent Utilization Review. Fortunately, I was not alone, or I never could have accomplished it. Mrs. H had enlisted a senior surgery resident who had cared for her in the past. He was no longer directly involved in her care, but he gave me ideas for ways to deceive Utilization Review. I would end every working day with Mrs. H, planning our strategy. After I finished checking up on her, she would check up on me. How had my day been? Was I getting enough rest? How was my husband and my life outside the hospital?
Within two weeks I ran out of tests to order and results to track down. Utilization Review had caught on and they made arrangements to transfer Mrs. H back to the nursing home. The surgery resident had a suggestion. Mrs. H could no longer eat, because her intestines were blocked with tumor. She was dying of malnutrition. That’s not a bad way to die and there was really no reason to treat her malnutrition, since treatment would only prolong her life to no purpose. The resident suggested that I arrange for placement of an indwelling catheter in Mrs. H’s chest to provide for intravenous nourishment. That would certainly buy a few more days of hospital time and she was dwindling quite rapidly at that point.
Mrs H and I discussed it. She was enthusiastic even though I warned her that the placement would be painful, and that she really didn’t need the catheter at all. She insisted that she wanted it, if that’s what it took to prevent the impending transfer.
There was just one hurdle in the way. I had to ask permission from Mrs. H’s personal doctor, the one who was really in charge of her care. I sought him out and began my rehearsed explanation as to why Mrs. H should get an indwelling catheter to ward off malnutrition. He listened politely and then looked me in the eye.
“Don’t think I don’t know what you are doing,” he said.
I froze, and readied for the tongue lashing that I knew was coming.
“Don’t think you fooled me. I’ve known what you’ve been doing all along,” he said, not unkindly. “You’ve been trying to trick Utilization Review into letting Mrs. H stay in the hospital to be with the nurses when she dies.”
That was it. I was caught. But I was unprepared for what came next.
“I approve.” He smiled. “I’’ve known Mrs. H for 35 years. She was one of my first patients when I started my practice. She’s a good woman and she has no one to care for her. The nurses are like her family. We can’t make her better; the least we can grant her last wish.”
“I approve of the catheter,” he said. “And I approve of anything else you try to do to keep her here until the end.”
Mrs. H got her catheter. The insertion was uncomfortable, but once it was in, it didn’t seem to bother her. It also turned out to have an added benefit, besides allowing her to receive nutrition that she didn’t need. It was an excellent route for the ever greater quantities of morphine that she required in the last few days.
Everyone worked together at the end to be sure that Mrs. H was comfortable and supported by the nurses whom she loved. I was not there the night she died. I had gone home for the evening, but the surgery resident she was fond of was with her as she drew her last breath.
I was sad that she was gone, but elated that I had been able to fulfill my promise. Mrs. H had had the death that she wanted.
A few weeks later I was paged to the lobby of the hospital. I had never been paged to the lobby, and couldn’t imagine why I was needed there.
A young man was waiting for me. He introduced himself as Mrs. H’s great nephew. He handed me a jewelry box.
“We read my aunt’s will,” he said, “and she wanted you to have this. Thank you for taking care of her.”
The bracelet is heavy and elaborate. It is not my style of jewelry, so I haven’t worn it. But even after 25 years, I still keep it in the top drawer of my dresser and think of Mrs. H.
