She looked good, all things considered. She was dressed simply yet elegantly, as if she had gotten dressed and primped a little before coming in. In retrospect, she probably had. My mother would never have considered going to the ED before she had taken a shower and gotten ready; it was just how she was, and this elderly beauty was the same.
I took my normal history and physical, asking all the regular questions, making the occasional jokes as I have a tendency to do. She smiled, and we started a chest pain workup. I rarely ask the DNR questions. It is something that I should probably do much more regularly, but I often forget in the heat of the moment. I have absolutely no idea what prompted me to ask them in this specific case. Not. A. Clue. But, for whatever reason, call it gestalt, hunch, or just plain luck, I asked.
Me: Ma'am, if your heart stopped beating or you needed to be resuscitated, would you want us to perform CPR or put a breathing tube in?
Her: Son (when you are over 80, you can call me Son, Sonny, Kid, or Poopface, for all I care), I have had a great life. If it's my time to go, just let me go. I don't want anyone banging on my chest or putting tubes in me to help me breathe. I don't want any medications keeping me alive. If it's my time, just let me go.
Me: Yes, ma'am.
So off I went to see patients in other parts of the ED. I don't recall the other patients I saw that night. All I remember is that sometime later a nurse called me urgently back into her room.
You can guess the rest.
Her blood pressure was 56/24. Her heart rate had increased to a million. Whenever a person is crashing hard in the ED, the room seems almost magically to fill with people ready to help. I had four nurses, three techs, and an assortment of minions ready to medically kick butt and take names. It was then that I did the one thing that never comes easily to an emergency physician.
I did nothing. We let her go.
We did not start pressors. We did not intubate her. We did not start CPR.
Her blood pressure continued to decrease to nothing. I turned off the cacophony of alarms. We watched her die.
Could we have intervened? Of course. We likely could have gotten her back. But it wasn't what she wanted. She had been very articulate on that point.
We let her go.
We see death more than most in the ED. Usually patients come in nonverbal. Distancing myself emotionally is easy when a patient comes in unconscious and actively receiving CPR. But it changes everything once I have a conversation with a person.
But this is true in all of life. Once connected, we create a bond that sometimes can be hard to let go. What can be dangerous, however, is if we cling tightly to the things that actually are doing us harm.
Letting go can be the hardest thing in the world.
Personally, I have a tendency to cling to painful experiences.
Letting go of the mistakes, embarrassments, and failures I find difficult.
I am not an introvert. I can be boisterous, flamboyant, eccentric, and just plain loud. But sometimes the loudest voice of all for me is the one inside. You know that voice. That dirty little jerk who hides in your mind, putting you down. That voice that whispers, “You should be doing more,” “You'll never really make it,” “You should feel bad about that.”
I can be my own worst enemy, silently berating myself and tearing myself down from the inside. I know many people struggle with this as well. Do any of you ever do this? The world is more connected now than it has ever been, yet I think people often feel more alone now than ever. You can have 2000 “friends” on Facebook and feel so alone inside it hurts.
Sometimes the best intervention is just to let it go. Stop beating yourself up over past failures. Let it go. Stop ruminating about an ex or a betrayal or even that time you did everything right and still did not get what you were hoping for. We're not really all that alone, no matter how much that sinister voice might whisper.
Let it go.
Let me know if you ever need a hug.
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