The family arrived after the 10am appointment time. We gathered in a windowless room where I and the doctors stood as our patient's wife, son, daughters and son-in-law sat before us. I took the lead "...Your husband remains very sick on the ventilator with no sign of meaningful recovery. As you all know you presented an affidavit that tells us that your husband and father would never want to spend his last days on a ventilator. The affidavit has now been approved as clear and convincing evidence by our legal department and this means that we can fulfill his wishes as transmitted by you -his loving family- and remove him from the ventilator". The family had some questions; "He looks better today than yesterday, does this mean anything?" A good question. We had noticed that the edema had subsided and his oxygen requirement although high at 50%, was the best in weeks. This seems to happen a lot. A profound decision is made and a patient suddenly starts looking a little better. I cannot say it does not perplex me and make me question the process. There is nothing certain in life or death.
The medical team is confident that the changes are unimportant in the bigger picture of this patient's multiple morbidities and we say so, but we all 'caught ourselves' momentarily inside, I know.
"That's it we have no more questions".
I go to the room, the morphine is running lightly and smoothly, the patient is unconscious but moves and can cough. I move the bed to sit up my patient to a comfortable position. I prepare the non-rebreather mask, remove the ties that hold the breathing tube in place. There is no room for the whole family between myself the ventilator and the IV poles. There's a lot of straining and reaching. I deflate the cuff on the ET tube and quickly hit the mute button on the ventilator. I pull the ET tube out and cover it with a cool blue chuck.
Mr. Saieed breathes without any distress. I change the alarms on the bedside monitor, it will only alarm if the heart rate goes below 25, and the other parameters I disable. I suction the patient's mouth and wipe his lips.
I tell the family "He has his wish, talk to him, be with him. I will be here for you throughout the day."
A couple of hours later I get a call- I was already on my way. One get's a sixth sensual feeling for these things. I arrive, the patient's vital signs have ceased; the numbers returning to zero. The family is distraught. They are talking to him. They are loudly saying his name touching him seeking a response. "Pa? Pa?"
This too is something I have observed. A medical team can never anticipate the crashing orchestra of emotions and memories that accompanies the death of a unique loved one. The finality -although perhaps often clear to us- is rarely completely accepted by the family.
His wife runs to me and holds me crying, she puts her head on my shoulder, I hold her tight. Those cultural competencies and societal mores I read about fall back onto the pages of my old textbooks. The eyes of his daughters are intense clear greens filled with tears and unanswerable questions. They appear lost.
The family members cry and talk to him. His wife ungrips me and tells me "He never said a bad word to me in his life, never, he was a good husband."
I stay with the family briefly, but my work is mostly done now, I quietly continue to be -most importantly- a witness.
I exit the room, the curtains are partly drawn. Suddenly I am surprised as a huge cloud of smoke suddenly shoots out from behind the curtain with the intense pungent smell of incense. In a hospital unit like this, lighting anything is strictly forbidden. I know this. I am torn by the impropriety of the action. I stop to think momentarily. Then I smile and walk away.
