There is a loss of words with the sudden death of a loved one. To say too little is offensive and somehow diminishes your pain. To say too much is annoying, as if you have all the answers. We all go to the phrases: I’m so sorry. It will get better. They are at peace. It’s not fair. I’m praying for you. Let me know what I can do.
The last one is my favorite: Let me know what I can do.
I am a doer. I was raised believing if you work hard enough you can make things happen. Want good grades? Work harder. Want your team to win a state championship? Practice more. In general, this is the key to success: Work harder.
Guess what? Stop working so hard! It does not fix all the problems. Stuff happens. People die. Life ends suddenly. When we put the expectations of perfection on our shoulders we are set up for failure.
Physicians are the worst at this. When things go well we say, “Of course; it is my job to save that life.” When someone can’t be saved, we question every move, wondering what could have been done better. Perhaps it’s time to focus on gratitude for all the great outcomes, and to have faith that the bad ones were out of our hands.
Last week, my father-in-law died suddenly. Actually, it was like Ernest Hemingway said about going bankrupt: It happened slowly then all at once (paraphrased). Jeff had poorly controlled diabetes for years — no one knows exactly how long because he hid his ailments well. An accidental discovery of insulin in his fridge revealed the hidden truth. When asked, he responded, “Don’t worry about it. Sometimes my blood sugar is high.” He wasn’t talking. He also wasn’t giving up pizza, beer, cupcakes, and all the joys of life. This stubborn father of five and grandfather of nine kept living, laughing, and pretending nothing was wrong.
A few months ago, he told us he had a problem with his aorta. With severe aortic stenosis he would need surgery within the next year. In early December he complained of having the flu, with weakness and gastrointestinal symptoms. Some days he would improve, then he would feel sick again. The entire time, multiple children asked him to go to the hospital. On Christmas Eve he was so thin, gaunt, and unlike himself I thought he had cancer. When asked what was going on he shrugged it off, attributing it to the viral illness. Everyone recognized that something was killing him, but we all watched silently while he declined over a few weeks.
Looking his worst, he finally caved last week and went to the emergency department (ED). By this point he was jaundiced and very weak. His blood pressure was low and he had an acute kidney injury. The hospital staff worked him up for sepsis, cholecystitis, obstructive stone, C. difficile, and basically everything you can think of. Antibiotics were started. Fluids were given generously, which put a strain on his heart. He decompensated and was placed in the ICU. Dialysis was needed but didn’t help. He was intubated. His lactic acid climbed from 8 mg/dL to 10 to 25 on the last day. His troponin was over 50,000 ng/L by the time he passed away.
I know all of you are trying to solve the puzzle of what could have been done. No, he did not have an obstructive cause for the liver disease. No, he was not a heavy drinker, but he did continue to drink alcohol occasionally while he was switched from insulin to semaglutide (Ozempic) by his primary care doctor last year. This probably didn’t help. No, the doctors did not miss anything or screw up.
In the end, this was a terrible conglomeration of illness that cascaded out of control and couldn’t be reversed. He was too sick for transfer, too sick for valvuloplasty, and too sick to survive.
The outcome would have been the same. At least that is what I have to tell myself as the one who watched this train wreck. My husband’s siblings who are not physicians ask: What if? They blame themselves for not getting him the valve replacement earlier. They blame themselves for not getting him in the ED earlier. Guilt wakes us up in the middle of the night. I also carry the burden that my father-in-law died on my watch. I am a physician and didn’t listen to my gut.
My husband, thankfully, blames no one. He points out that we tried to change this course over the last 4 years. After my father died from pancreatic cancer, my husband and I went mostly vegan. We gave his parents a copy of “How Not to Die.” We bought his dad an air fryer, which he loved for cooking lobster. We stopped serving dessert to any adults in the family. I pushed tea instead of beer and wine. No matter what we could have done, the destination was the same. He was bound to end up in the hospital with multiorgan failure and severe aortic stenosis.
At the end, we stated: No code, please. He was on every pressor, and with his blood pressure dropping and lactic acid climbing, there was nothing else to be done. After giving the family time to show up and say their goodbyes, the priest gave the last rites and we let him go. It was awful. Absolutely the worst — but strangely beautiful. Surrounded by his children, brother, and wife, he took his last breaths, peacefully.
I share this to give perspective as a family member, an insider to the devastation of declining health and death. We all blame ourselves when things go wrong. When things go well, we are rarely grateful for long. Please be grateful. Know when you do well. Remember always that the majority of patients are grateful for your help and efforts.
Don’t quit medicine because it is hard. Lean into it. Learn from every bad outcome and give hope to families. When there is no hope, give them words of peace and understanding. We are Healers, but we are also there to navigate the end of life and explain when nothing can be done.
And to his medical team, we are eternally grateful for your efforts.
“Tell us please, what treatment in an emergency is administered by ear?”….I met his gaze and I did not blink. “Words of comfort,” I said to my father. — Abraham Verghese, Cutting for Stone
Heather Optholt, MD, is an emergency physician at Lutheran General Hospital in Park Ridge, Illinois.
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