A Case Presentation Becomes a Morning Meditation
By D. Preston Figge, M.D., physician and staff chaplain
It was gathering time for the monthly Clergy-Clinical-Conference. The breakfast buffet and the carafes of coffee provided early morning nourishment. Physicians, chaplains, nurses, and others assembled around the hospital boardroom table exchanging pleasantries. The panel, an infectious disease specialist, the nurse manager of the patient’s unit, and I, the chaplain, were preparing for the case presentation of a patient who recently died in the hospital.
The physician related James’ medical history. He was admitted through the emergency room on January 22 complaining of severe weakness and cough. A complete medical evaluation determined that he suffered from Stage 4 cancer of the esophagus with metastasis to the liver and active pulmonary tuberculosis. Oncologists were consulted and initiated chemotherapy, and the infectious disease physician started anti-tuberculosis therapy. After a few weeks of therapy James’ condition deteriorated. Because of his active infection he was not eligible for transfer to a long-term care facility. It became apparent to everyone that James was going to stay in the hospital until he died.
The physician, concerned the news that nothing more could be done therapeutically would be emotionally devastating to James, scheduled a case review conference to discuss and initiate measures that would allow James’ last days to be as comfortable and dignified as possible. The conference included physicians, nurses, chaplains, administration representatives, and social workers. All agreed to coordinate their activities and procedures related to care during his final days.
The nurse manager shared her perceptions of James’ situation. She and the staff became very attached to him. She appreciated the fact that the hospital administration representative said that no financial hardships would be placed on him. She organized the staff schedules to be certain that James would be visited regularly. No one was eager to visit him because of the cumbersome infectious disease isolation precautions requiring masks, extensive hand washing, gloves with contact, and often gowns. Despite the precautions, there was a latent fear that tuberculosis could be contracted from encounters with him.
James shared that there had been little contact with his family for several years. The nurse manager contacted his family, explained the situation, and strongly urged them to reconcile with him. His children and his brother responded by visiting frequently. Her son’s closet provided used clothing for him to wear.Despite all this, due to the strict confinement to the hospital room that had no windows be became quite anxious. The room next to him that had windows became available and he was transferred. Periodically, he was taken outside in a wheel chair. He was allowed to smoke in his room with supervision. The nurses appreciated the fact that he cooperated and seemed to understand the need for the rules and restrictions.
I then discussed my impressions of James and his care. He related that he was a loner and worked most of his life as a bricklayer traveling from city to city practicing his trade. Because of the weakness due to his illnesses he had become unemployed and was living with the friends who brought him to the hospital. The “bottle” had been his best friend for years. He experienced incarceration in local jails quite frequently. He was divorced and estranged from his children. The last time he had been with his brother and two sisters was at the funeral of their older brother who died from cancer several years ago. James had arrived at this point in his life unable to work, with little money, a few clothes, fewer friends, and no family he felt he could contact.
Despite his rough life as a loner, James seemed to be a quiet and gentle man. He admitted he had put God on the “back burner” but was now interested in seeking a relationship with Him. His daughter brought a Bible that he read frequently. I recommended the Gospels of Mark and John as starting points. I noted that it was always open on the table in his room when I visited. He later reached a point on his faith journey that he felt at peace with God. He became more relaxed as the end neared. He appreciated the visits from his family and everything the staff did for him.
One day as I was masking for a visit, one of the members of the housekeeping staff on his floor passed me wanting to go in first. She said she was going off duty and wanted to see if James needed anything before she left. The nurse manager told me that the housekeeper was on the volunteers who transported him outside in his wheel chair. Also, after obtaining permission, she brought cigarettes to him.
Early on the morning of March 21, I was paged to come to his room. On entering I noticed his face was covered with shaving cream. The nurse manager was leaning over him in his bed shaving him. She told me that James was in a lot of pain and was very weak. He appeared to be terminal. His family had been notified to come. Later she said that she wanted him to look presentable on what appeared to be his last day. James’ voice was very weak. He said that his “gut hurt.” I offered prayer, asking for comfort and peace for him. He stated that he was ready to die.
The family began arriving. His children came first. James asked his son to rub his feet. After he became anxious and uncomfortable, morphine intravenous drip was started for pain control. He then relaxed. His brother and two sisters arrived later. The nurse manager gathered the family in the conference room and notified them that death was imminent. Everyone cried. We had prayer together. All except his sister-in-law and I went back to his room.
She related to me that her husband and James’ sisters were not going to reconcile with him because of his estrangement from them. He was only with them for one day when their older brother died, then disappeared. However, after more discussion, they changed their minds, deciding to support him and also share the expenses of his burial.
During the day everyone was attentive to him. Later that afternoon he became very anxious,complaining of increased pain. His IV had infiltrated and he was not receiving his pain medication. The nurse attending him seemed uncertain about her ability to restart his IV. She suggested giving him intermittent shots that would be painful and not as effective as a continuous infusion. Not satisfied with that approach, I walked down to the surgery suite and explained the dilemma to one of the anesthesiologists. He immediately responded and restarted the IV. When I arrived back at his room, James was already more comfortable. He died peacefully at 0300 the next morning.
Silence followed the presentation for several moments. We all remained in our chairs. Tears welled up in many eyes. Usually after the presentation, we quickly get up, leaving to begin our daily schedules.
Someone in the end of the table quietly commented that this was an example of how care at the end of life ought to be for everyone. The Director of Pastoral Care offered prayer. We filed quietly out of the room. The case presentation demonstrated that underneath the fast paced technology driven often seemingly uncaring healthcare system is a flowing stream of compassion desiring opportunities to provide patients with a dying and death experience that recognizes the value of each individual’s need to be loved and respected at the end of life. For us that morning, a case presentation was transformed into a meditation.