in case i don’t see you again

In case I don’t get to see you again… I knew only bits about Mr. G. The bits that don’t really matter. I knew what medications he had been prescribed. I knew his blood pressure. I knew his weight. But I knew nothing about the bits that mattered. What brought him joy. Whom he had loved. Why people had loved him. What he had once hoped for himself. What demons drove him to drink to hopelessness.

It was my third time seeing him. Still, I felt the tears rise in my throat as I spoke the words.

In case I don’t get to see you again…

He looked like an anorexic, 9 months pregnant with triplets.

a patient with tense ascites
a patient with tense ascites

His belly bulged with ascites, fluid accumulating because his liver could no longer make the protein to keep the fluid inside the blood vessels. I reached out to touch his belly. The skin was as taught as it had been 7 days ago, though a needle in his belly had drained 6 liters of the fluid away in that time. He was still wearing the Band-Aid that covered the hole the needle left. It still hurt there. He was short of breath. It was hard to walk.

We could not stop the fluid from coming back. He liver was dying. He was dying. Dialysis could not change that. And without six months of sobriety (or celebrity status) he could not get a new liver. He would not live that long. Maybe weeks he had. Probably not months. Definitely not years.

We nephrologists used to understand this. And because we understood this, we did not offer dialysis to one in this situation, even though the kidneys fail too in the face of liver failure. Dialysis could replace some of the kidneys’ function, but dialysis wouldn’t do a damn thing about the dying liver. But for some reason I don’t fully understand, within the last five years ones in this situation are being offered dialysis.

I begged my colleagues NOT to offer Mr. G dialysis. They didn’t, but they left it for me to tell him no. Dialysis was not a rational option for him, even though the numbers said his kidneys were failing.

And so I did. It took time. This ain’t no 15 minute visit. It was hard. To tell a person he is dying. Even though he already knows.

He agreed to accept hospice services. They would help get him comfortable and keep him there. They would ease the fear of what was to come. He would not need to climb up and down the stairs to his home to go see them; they would come to him.

I increased the furosemide (Lasix), the water pill, hoping it would help him pee off the fluid accumulated on his legs. I refilled the lactulose, hoping it would help him shit away the toxins of liver failure so he could be clear enough to interact with his best friend who was crying already. I prescribed hydromorphone (Dilaudid) to help with his pain and his shortness of breath.

I stopped the iron, the phosphorus binders, the sodium bicarbonate, the blood pressure pill. His eyes and he best friend’s eyes widened with “are you sure?” Don’t we need those pills? No, I told them. They will not help increase his comfort, I told them. He was told to not eat salt, the best friend said. He should eat whatever he wants, I said.

I begged the Interventional Radiologist to put place a plastic tube through his belly skin that would allow the hospice nurses to drain the fluid away without having to stick him again and again. They would work him into their over-scheduled schedule on Monday. It was Friday. I prayed he wouldn’t end up in the hospital before then. Because things happen in hospital. Things that I was hoping to spare him because they don’t matter. Things like chest compressions. Shocks to the heart. Dialysis. Because it is easier to do, than it is to say no. Than it is to stop doing.

In case I don’t get to see you again… there is something I want you to know. It has been an honor to take care of you, I said.  And it was.

I wished I’d had something specific to say to him. But I only knew the bits.

I was wrong. He only had 2 days. He died at home on Sunday, before the tube could be placed to drain his ascites. I hoped he wasn’t short of breath when he passed.