I Helped One Grandmother Live and Helped Another Die

The healthcare system snaps to attention to prolong life, but it doesn't always do the same in making death comfortable.
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I saved both of my grandmothers. One, I helped live. The other, I helped die.

Doctors found a large mass in my maternal grandmother’s abdomen. It was curable, they said, and with surgery she should do well. As a third-year medical resident, I was elected by the family to fly to Montreal, where I would keep a medical “eye on things.” The surgery went smoothly; we all breathed a sigh of relief. The next day, we went to the hospital for what we expected would be a quick goodbye on our way to the airport. But something was wrong.

She couldn’t talk and mumbled incoherently. It was Thanksgiving Day and there was only a skeleton staff present. Her urine bag was empty and the blood pressure cuff in the room didn’t register a pressure. My worst fears were confirmed. She was in septic shock, dying.

No doctors were answering their pagers, so I commandeered the floor nurse. My grandmother needed fluid, I told her, a lot of fluid, or she would surely die. I managed to convince her, and the nurse began a rapid infusion of fluids. I then paged the physician myself, explaining the urgent situation. My grandmother was prepped and draped in the operating room within 30 minutes. A four-hour surgery ensued.

She went on to live another 10 years, saw the birth of two grandchildren, and died with her children at her side.

My other grandmother died a decade and a half later. By that time, I had been practicing ICU medicine for years, and I was as aggressive at lifesaving as a Saint Bernard. But I had also acquired another skill—one I had not needed with my first grandmother. I now knew how to help the dying die.

It had taken me time to learn that death is ultimately unavoidable. I had seen too many cases where bodies were stretched beyond their natural lifespans like old, dry rubber bands. Our life-prolonging ministrations could not restore them.

I had learned to work in new ways with my patients to make sure that they understood the meaning of life prolongation. For some, it might keep a body going until quality of life was restored, but for others, it could prolong an already unacceptable condition.

Once they understood that, most people chose to die comfortably.

After 10 years of profound dementia, we all knew grandma would want to die peacefully, not at the end of a machine. She was enrolled in hospice and received wonderful care in her home. When she finally developed the aspiration-induced pneumonia so common to patients with end-stage dementia, she was admitted into the hospice facility for aggressive comfort management.

When I arrived at her bedside, she was delirious and short of breath. A pulse oximeter next to her bed showed that she only had 79 percent oxygen saturation in her blood, a critically low reading. It was a Friday night and, like deja vu, only a bare-bones crew was on. Where was the nurse? Why wasn’t grandma being given medication for her shortness of breath? Why wasn’t her delirium being addressed? Why was a pulse-oximeter on her finger when what mattered were her symptoms, not her numbers?

Again, I snapped into action. This time I wasn’t trying to save a life, but rather to midwife my grandmother through her death.

This time, I was unable to rally the troops. My request for help from the nurses was met with resistance and distrust. I had to fight for a dose of morphine for my grandmother, even though it was ordered in her chart to be given “as needed.” When it was time for a second dose, my request was followed by whispers at the nurses’ station. The rest of the evening played out in a tragic war, with me as the villain. My grandmother died the next morning, not as calm or comfortable as she might have been.

It has taken me years to come to peace with the way I was perceived by other healthcare workers during my second grandmother’s death. They were suspicious of a granddaughter who was not fighting to prolong her grandmother’s life. To them, my requests for morphine triggered the notion that I was trying to shorten her life further. (Opioids do not shorten life in patients at the end of life, a common myth even among doctors and nurses).

These two experiences were so diametrically opposed that I knew it couldn’t simply be about me. As a little punk resident, I was able to rapidly mobilize an entire surgical team within half an hour to save my first grandmother’s life. Later, as a highly trained ICU attending physician, I struggled to get a dose of morphine for my other grandmother as she lay gasping for breath.

It says something about the way we practice medicine that it was easier to mobilize the medical troops when I was rushing into a life-prolonging battle than it was when I was working to ease the inevitable.

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Jessica Nutik Zitter

Jessica Nutik Zitter, a physician in the San Francisco Bay Area, is currently writing a book about end-of-life care in the nation's ICUs.

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