Sunday, April 15, 2012


   Saraswati was readmitted to the hospital.I was called again . I saw her for the first time , when she was admitted few months ago . In last year she was in the hospital 4 or 5 times.When I saw her for the first time she was admitted with the fluid around the lung and was short of breath. I drained the fluid and did the work up . It turned out that she had a liver disease, cirrhosis of the liver . When I got the additional history , the husband told me that she had hepatitis in India . She had gotten worse in recent past . She was not a smoker and never drank alcohol . She was 'Hindu ' and ended up marrying a christen . The husband was quite stubborn , but loved his wife very much . She was 69 years  and was not in the best of the health.Her real name was Saraswati --name of a  Goddess  of  Money and he being Cristen changed to Sarah.
   Her hospital course was very intense,as the diagnosis was not established before . We took out the fluid from around the lung , we also did drained fluid from the belly . We did liver scan , cat scan of the chest and the belly. We also ended up doing liver biopsy to confirm the diagnosis of cirrhosis of the liver . She also had some kidney issues. , was anemic with low blood count and had low platelet count and blood did not clot normally . Most of these abnormalities were due to the liver disease.
     I had explained the grave nature of the disease and the poor prognosis to her and the husband . She was OK with it and accepted it quite well. He was not at all comfortable with idea of poor out come . She was older and  liver transplant was not an option 25 years ago . We had every speciality MD see her , Gastroenterologist , cardiologist , kidney specialist , blood doctor and myself, lung specialist .We discharged her on medication , fully well expecting that she will be readmitted .
    So over period of time she was in the hospital few times . Each time her condition was getting little worse in spite of the medications .
     Now she was in the hospital and this time she was in Intensive Care Unit.I saw her and talked to her husband. She had same problems , but all of them were worse . Her kidney function was wore, her liver chemistry was worse and her blood counts were worse too.
    We again had same group of doctors see her . Her liver was giving   up  and the level of ammonia --the liver is suppose to get rid of it - was climbing . Over period her urine out put dropped and accumulation of waste products, called BUN and cratinine were climbing. Her billirubin was getting worse .I had several conversations with the husband . I had told him in the beginning subtle way and when this was not effective , told him in no uncertain terms. She now was hypotensive ( blood pressure was low ) needed to be put on respirator and needed dialysis, as had no urine out put . She also needed transfusions repeatedly and was almost comatose due to 'waste products ' accumulating in the blood . Every time I tried to talk hi about making her  DNR--Do Not Resuscitate- he would say same thing 'Don't you believe in the Jesus, He can perform miracles . ' I had no answer to this  line of thinking . Granted that The God can do miracles , but if he did it every time it would not be 'miracle ' and no n one  would die .
      It was month of December and now she was in the hospital for 40 days . Her blood pressure was low , needing medicine to keep it up for 5 days and she was on dialysis for last several days . Sometimes we had to stop the dialysis as her blood pressure would drop with the fluid being taken out. We also needed transfusion and respirator support, and intravenous feeding was limited due to fluid balance issues. We had 'ethiques committee meetings , but he was not listening to any one and was not ready to accept that his wife--whom he refused to call Saraswati -her real name -Sarah - was not going to survive . I tried to tell him that he was being 'selfish '  and his wife was suffering . ( I was going to use word 'torture' , but I avoided it ).
  It was 25th of December and I was making my rounds . The patient load was light , but still lot of 'sick ' people were still in the hospital . ( At the time of these days only very sick patients continue to stay , rest of them want to get out as quickly as they can . )I spoke to him again . NOTHING HAD CHANGED . She continued to 'Hang in ' . I took him aside . I told him  that for practical purpose we were keeping her alive  with machines and dialysis and medicines . But more so that HE WAS HOLDING HER . If he would not resist she will go . I also told him that we should make her DNR and continue what we were doing --medicines, dialysis, transfusion , feeding etc , but if her heart stops or blood pressure drops then we will not do CPR or 'shock ' her . I don't know why , but he agreed to the DNR , but made me promise that we will not hold any treatment. I did that , but then said , "I want you to do me a favour. I think that she is 'there ' because you are 'holding ' her , if YOU could 'tell ' her that YOU will be OK , and she can 'GO ' she will go , ". He was not sure as to what I believed and definitely did not believe in 'this kind of thinking ' .  I  told to do it for me .  He agreed .
    We went in the room . He held her hand . and told her that 'she can go and he will be OK . '
     Saraswati died in less than 10 minutes, after his statement !!!!!!!

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