You Killed My Mother

Martha's death was difficult but not unexpected. She had been in and out of the hospital three times in the past six weeks. Her husband was there at the end.

About an hour later I got a call from the son, John, who hadn't been around much. He was upset, angry and aggressive: "Doctor, you killed my mother. I want to meet with you and my lawyer there today!"

I think I must have surprised him by saying, "OK, how about 2PM today." I had just had a patient cancel and had a free spot. I arranged for a conference room since I didn't know how many people would be there. Medically, I didn't think I had done anything wrong and was reluctant to generate unnecessary tension. I was pretty certain that if I called the hospital's legal department that they would want to meet with me first and then perhaps be at the meeting. I had been in enough contentious situations over the years and I didn't want this one to escalate. Also, I had enough gray hairs, that I'd been in similar situations before.

So I ordered up all Martha's records and took them to the third floor conference room next to the library. Four family members arrived: John the son, Ed the husband, Mike the brother-in-law and Sue the patient's sister.

I asked whether their attorney was coming, and Mike said he was a tax attorney in Seattle. So John's initial challenge that he would bring "his attorney", turned out to be a family member who wasn't a litigator.

After introductions, I asked John what the concerns about his Mom's care were. He said, "I think she got too much morphine and it killed her."

I said, "Let's review the care and medications she received. Here's the chart so we can all review it and look at the medication record and the nurses notes. First, I think we all know that Martha had very severe emphysema. At age 81 she was weakening and her lung function worsening despite aggressive use of prednisone and inhalers. Infectious were vigorously treated with antibiotics. But she was slowly suffocating even with oxygen."

Mike said, "Well, where does the morphine come in."

"Good question. Martha had decided that she didn't want to be put on a ventilator because her quality of life was so poor, yet she felt panicked often being unable to catch her breath. She said she felt like a fish out of water. Indeed her carbon dioxide was climbing and her oxygen levels falling in her blood gas samples. The end wasn't far away."

"OK, but what about the morphine, John interjected."

"Well, your Mom was becoming agitated, not making sense and beginning to cry out. At that point I talked to your dad, John, and told him morphine or a sedative would help your mom be more comfortable. So we began small doses to try to titrate care for comfort."

Mike said, "Is that right dad?"

"Yes, Martha was so uncomfortable and so confused. I felt we needed to do something to make her more peaceful. I felt she was dying."

"Let's look at the medication sheet. The nurses gave her 1 or 2 mg of morphine at each of these times over a three hour period. The total dose was 10 mg. Although it could be argued that the morphine speeded up her death by a matter of minutes, the morphine did several positive things for her. It releaved her anxiety, decreased her sense of shortness of breath, and basically relaxed her as she drifted into sleep and ultimately death. Without the morphine she would have had a miserable death."

By this time John had calmed down and began to realize that he needed to support dad. I relearned the lesson that all family members need to be involved at the end - with active outreach if they aren't there. There seems to be a direct correlation between anger and distance from care.

Comment: Over the years, I would come to insist that all family members be involved in the family conferences. We would arrange conference calls so "Aunt Minnie for Minneapolis" could be there and feel included. Allowing all concerns to be addressed, transparency of medical records, admitting our own shortcomings, and wishing that things were different were all "OK." In this case, I should have brought John, the son, in much earlier so he could understand the issue of palliative use of morphine in end stage lung disease.