His heart had been failing for weeks, but that day we found out why: a primary cardiac sarcoma. The rarest of the rarest cancer was engulfing the right side of his heart and squeezing it to death. His wife asked us not to tell him the results when he gradually awoke from his post-anesthesia haze after the TEE. Just let him have one more night without anxiety.
Hours later, his heart rate and blood pressure took off in opposite directions. His consciousness flickered on and off as we started pressors. We called the wife back into the hospital overnight.
Of course we would wait for the formal oncology opinion in the morning, but the options were dismal. No surgery and low chance of chemo-responsiveness meant CPR and intubation would not be in his best interest. Tissues lined the bright pink DNR/DNI form that we filled out together in a windowless family room. As I stood to leave, the wife said, “I can’t bring myself to tell him. If he wakes up, I need you to tell him.”
We entered the ICU and found that the pressors had indeed given him more awareness than before, but delirium still lingered.
I sat on the edge of the bed and the weight of the necessary discussion made me sink further.
I started by telling him the results of the TEE. I explained that he had to be moved to the ICU because he was now requiring medications to help his heart pump. I told him that he was showing signs of confusion, so his wife and I had a discussion about what he would want if he were able to understand all the complexities of his care. I told him that we would do everything short of CPR and intubation, but that I was worried because there was no obvious answer to reverse his heart failure. He quietly asked me how much longer he had, and I had to answer honestly that my best guess was hours to days. Hours.
His eyes went from unfocused and glazed to wide with absolute terror. I will never forget that look. He may not have been clear prior, but he was certainly aware that I had just given him a death sentence. No matter how much reassurance I tried to give, that he would be comfortable, his wife was with him, we were so sorry we had no more therapy to offer him, he just looked in horror from me to his wife, who burst into tears. And why would anything I said at that point be helpful? Nothing after the word “hours” mattered. When pressed to put a number to the inevitable it felt as though I was the one in control of his remaining moments. I wished nothing more than to be wrong.
Multiple times during the night, as his delirium waxed and waned, he asked his nurse to call me back to explain everything again. It broke my heart each time. He finally fell asleep, and passed peacefully the next morning surrounded by his family. My solace lies in the fact that he is immortalized in my memory far longer than the hours I gave him.
Danielle Wallace is a second-year Internal Medicine resident at URMC. She enjoys using reflective writing as a way to process the challenges and joys of medical training, and has started writing groups to encourage other residents and medical students to do the same. Her work has been published in JAMA, The Pharos, Family Doctor and now murmur.