Tuesday, January 19, 2010

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.

7 comments:

  1. Well done! We can't always get everyone at the table in a timely way, but your timely response and honest sharing went the distance you couldn't cover earlier.

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  2. I just came upon your blog and it brought to the surface again my anger and pain over the way my middle-aged brother died recently. Much of what happened to him can be explained by family dynamics and cultural medical attitudes (he lives in another country), but I’m still having a heck of a time dealing with my inability to help him die with as much dignity, peace, and physical comfort, as possible. A couple of days before he finally succumbed, I yelled over the phone to his daughter to have pity on him and beg some rare compassionate doctor to give him some morphine. After watching closely the course of his illness, re-reading about approaches to death like the one you’re describing (that may not be the norm in this country either) sometimes feels like reading Science Fiction.

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  3. When my mother died my siblings and her boyfriend said there "goodbyes", at which time they took her off all the machines that "kept her alive", and she started doing ok. So since she wasn't dying fast enough, they gave her morphine which lowered her blood pressure(which was the issues she was having to begin with) and it killed her. She was in a coma and was not in any pain, so why the need for morphine, if not to kill her?

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  4. Anonymous: I can't really comment on the specifics of your mother's death. It must have been sad and traumatic for your family. I'm sorry that it went that way. Each one is unique and so many variables are involved. If your mother was "doing OK" then the use of morphine may be questioned. On the other hand if gasping, severe shortness of breath, or pain is present then morphine can be amazingly effective in symptom relief. Medical societies approve the use of morphine when the intent is to treat symptoms. No one approves its use if the intent is to kill. It might be useful to ask the doctors to review the care with your family.

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  5. I found the link to your blog in the New York Times. What a wonderful doctor you are. Delighted you are in the world with your wisdom, experience and humanity. Many best wishes from Dublin Ireland.

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  6. You are certainly to be applauded for going the extra mile with Martha's family, but as you said, medically you didn't think you did anything wrong. What if the opposite was true? Would you have been as open (and without lawyers)?

    The doctor who refused to intubate my father, telling me "he was dead the day he got here" and falsifying the records to omit his presence was not as forthcoming or generous with his time as you were (see Holycrosshealth.com).

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  7. In this case, it was to counter air hunger. In the case of the comatose woman, though, that was indeed terminal sedation.

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