Snapshot: The Eleventh Hour

Hugh Dowlen 

“I wish you could have known him before this.”

I am standing by the intensive care unit (ICU) bed of a 56 year old man with florid liver failure, acute kidney injury, and Staphylococcus aureus bacteremia. His sister, a few years his senior, is devotedly attending to his every need. She has told me this several times since we met several days before. She would go on and on about how he was such a great fun-loving person, a laid back personality and a wonderful conversationalist. We had made a special connection, she and I, the first time I encountered him as my patient. Her brother had arrived with an ammonia level of 109 with profound altered mental status and was found to have methicillin-sensitive Staph. Aureus (MSSA) in his blood. After a few days, his confusion had cleared somewhat and he was stable enough to merit transfer to the hospital floor. When his hypotension required pressor support to maintain his blood pressure, he came back to the ICU, and never left.

Over the course of two weeks, I became deeply involved in the dynamics of a dying patient and his family members. The patient had no designated healthcare power of attorney (HCPOA), and I learned from North Carolina law that a set hierarchy of decision making power was spelled out for an individual who did not have the capacity to make his own decisions. First the spouse, then adult children, then parents of the patient, and, lastly, siblings were the line of concerned parties to whom HCPOA was granted. That was the letter of the state law. Yet in this situation, the order of the family members who showed care and concern for the patient was the reverse.

First, a sibling. The patient’s sister hardly left his side from the moment he was admitted to the ICU the first time. She would sit with him and talk, would catch a smile or a rare moment of partial lucidity when he would speak a string of comprehensible words. She reiterated again and again what a neat man he was before his hospitalization.

Then, parents. The patient’s mother and father were concerned parties who cared for the well-being of their son. They traveled from hours away to be present in his last day of life, and in his death were present in the same room for the first time in nearly three decades since the dissolution of their marriage. This was a beautiful display of unifying love for a child who would precede them in death amidst a tragic set of circumstances.

Next, the adult children. The patient’s daughter arrived after her father had been hospitalized for several days. She expressed concern for him, but the biggest source of her distress was her own brother, the patient’s son. The medical team was in contact with him at several points in the process, and he repeatedly emphasized his intentions to travel from out of town to be with his father. Couldn’t he just have more time? He had just started a new job and did not wish to compromise his employment. After repeated promises that he was starting out in the car to reach his dying father, it became clear that he in fact had no intentions to visit.

Finally, the role of spouse. The patient had divorced years before, and it was evident from the beginning that his ex-wife was not to play a role in this difficult situation. The decision to withdraw life support ultimately came to the patient’s daughter and other family members at bedside.

A snapshot of five and a half decades of life. This is what played out in the ICU in my time rotating through this unit of the teaching hospital. What I learned from this set of experiences went far beyond the treatment and scope of disease, superseding hemodynamic collapse and multiorgan system failure. A lifetime of family unity and strife, fondly remembered times and tough times, too – these unique family dynamics have been in place, spanning years and even decades. And a hospital stay when a loved one faces mortality is but the end of a long road in the life of that individual. As a healthcare provider in training, I am gaining greater appreciation for the complexity of human life and the way it often ends. We see such a small fraction of a person’s life in his or her brief interface with the healthcare system, the last of many such encounters, in the eleventh hour. And that individual’s web of relationships, a lifetime in the making, comes to bear in those moments of trial, when difficult goals-of-care conversations take place. When the family elected to withdraw pressor support and the patient expired in the ICU, a man’s life came to an end. This is but another defining event in the life of a family.


 Hugh Dowlen  

Hugh Dowlen
Year in Medical School: MS4
Grew Up: Chattanooga, TN
College Attended: Davidson College
Favorite Quote: “You are much worse off than you ever imagined, but you are much more loved than you ever dared hope.”
- John Gerstner



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