Giannina L. Garces-Ambrossi Muncey, MD | Physician | October 25, 2018

There are medical honors so rare you don’t even know they exist. When you’re trudging through the slog of PBK/AOA/other — ultimately meaningless — letters, these seem to be the definition of distinction. Just like every other lesson, a patient taught me what real prestige is.

Well, it wasn’t entirely that Oslerian, it was the patient’s nephew.*

Carl paged me on an ordinary day — a fellow physician, he once saved my family’s life with the silent, brusque wave of a pen. His aunt, Sharon, had been hospitalized for weeks. Carl knew I wasn’t on service, but he’d heard about me. Could I just take a look, see if I could add anything?

The background Carl gave me soon proved essential. Sharon was a maternal force — she’d transformed his cousins (her sons) from window-destroying bottle rocket launchers into actual rocket scientists. She was also lonely. Her sister — who was her best friend — recently died of leukemia. Sharon knew about the end, the part where you stop responding to treatment. But she’d controlled stereotypes for decades— hell, she’d do “the end” her own way, too. She’d made her boys promise they wouldn’t “do the breathing tube.” They’d promised to “let her go.”

Then, just when she needed them the most — her boys changed their minds. They reverted back to bottle rocket launchers. Instead of firing at windows, they aimed legal threats at nurses. They were powerful, they said: they could have this whole place shut down. Listen to me! She was fine two weeks ago.

That’s when Carl stomped out to find me.

I walked into ICU room 10 and saw the morphine pump. Sharon seemed like a toddler in an adult-sized bed — all pillows and bedsheets, just tiny crumpled body in a field of white. Her fine hair seceded to patches of scalp, and her mouth was edentulous. Across the room, one son grimaced. His beige hoodie offset eyes so black that it was hard to tell if he was crying or analyzing. He said that she was proud, fierce. The kind of woman who raised us hellions all by herself in Dorchester. She never cried, “‘cept when we bleached her favorite Pats jersey … we just wanted to help Ma for Mother’s Day.”

As I walked out of Sharon’s room, I wondered how her sons were so young. Her enormous chart reminded me that she was 65, not 95. The chart filled in other parts of the narrative, too. She had meant to see her oncologist. She hadn’t noticed the oozing from her dialysis line.

Everywhere, dismal numbers of every type: vitals, labs, procedures. Every vasopressor maxed, every antibiotic titrated. Every consultant’s note signed with “poor prognosis.” The balloon-perfect nurses’ writing captured the weeks before the boys arrived. We’ve got meetings in the city; we’ll come when she’s better.

As I read through the chart, I reflected on what went unsaid: She was dying. And there are only so many ways to accept the point of dying — but I’m not sure I’ve figured out any of them. Sometimes, I think to myself, “God is calling you home.” Other times, it is “birth, inverted.” But mostly, death is our grand unifying theory — being human is a fatal condition. But how do you distill philosophy into practice?

In the ICU we had a little room for big talks. That’s where we met. It was just me, Carl and the boys. They looked at me with a frustrated hope we call anger. I looked back at them, empty. There was no data to add, no procedures to suggest.

So instead, I told them a story. It was the story of how we die now. I told them the pattern of it: little things — little falls that become hip fractures, little confusions that become delirium, little coughs that become pneumonia. “Little things” that add up so subtly, we forget to call them by name: multi-organ failure. We talked about how, sometimes, the only thing saving anyone is social support — once the safety net rips, it pulls us down with it. The beige-hoodied son fixed those eyes on me like steel.

This was a story, that, as doctors, we know so well: how we die In modern medicine. So, I apologized. I couldn’t give them any answers, and I couldn’t provide them with any cure. I could only say that looking back on it, Sharon’s history was a real one. It made sense from a physiological, medical and human perspective.

I was a little embarrassed. A colleague asked me for analysis, and I gave an anecdote — an anecdote that, deep inside, the boys already knew. The son with the beige hoodie turned and said simply, “It all makes sense now. It’s been happening to her for a long time, hasn’t it? ”

He proved me wrong with those eyes: close enough for a handshake; they were filled with tears.

We each left the family room empty handed that night — but something changed. There were no more arguments in Sharon’s room, no more demands over vital signs. Her morphine drip calmed her breathing, and her sons calmed each other. Six hours after starting hospice care, she stopped breathing. She stopped breathing, but she did not stop. Her story did not end. Each arc of her life had a record: birth, Dorchester, boys, family, death. But her family hadn’t understood the last part. They needed the final story to let go of her body, yet retain her spirit.

Looking back on it, that’s when I saw the greatest honor of all — the everyday honor of storytelling for our patients. Maybe that’s the only cure we have for death … translating what happens from the body into the world. Perhaps that is the last frontier of care: sharing the understanding of how we get to the end — just as much as how we got to the beginning. Maybe, we should reframe the last note we write for our patients — and make it the last story we share instead.

* Details have been changed, and cases combined, to protect patient and physician privacy.

Giannina L. Garces-Ambrossi Muncey is a critical care physician.