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Sadness, Guilt, a Lesson for the Next ED Patient

Walker, Graham, MD

doi: 10.1097/01.EEM.0000547696.96107.f0

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (, a medical calculator for clinical scores, equations, and risk stratifications, which also has an app ( , and The NNT (, a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns at



I've been fortunate not to have lost a close family member for 26 years, but it's a mixed bag. When both grandfathers die before you're born, there are fewer relatives to lose—and have. But I recently said goodbye to my last living grandparent.

I've been in the same situation with countless patients and their families over the years, but it was strange to feel it from the other side of the stretcher—to have the palliative care attending talk to me about my grandmother.

I think Nana had what we all really desperately want from life. She died at 91, with around 90 years of amazing health. She had aches and pains, arthritic shoulders, a broken hip, some hyponatremia, and an incidentaloma or two along the way, but none of the baddies that ruin quality of life: no diabetes, no cancer, no dementia.

She lived at home alone until a few weeks before her death. She showed her love in the kitchen; she probably baked at least 10,000 rolls from scratch by my calculations, and made every Thanksgiving and Christmas supper. She was an outstanding cook and baker.

Her last year was hard. She grew frailer yet remained just as stubborn, and at the same time grew more upset and anxious, worried that her bowels were off or that her tongue was swollen or even that she was still here. She tried the patience of her children when they tried to help. I would swoop in with the occasional phone call or visit over Christmas as the “doctor who is supposed to know everything” (her words), but the brunt of the stress, anger, and frustration was on my family in Kansas City.

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Frailty in the Elderly

One thing you don't really learn in medical school or residency is frailty and deconditioning in the elderly. These are often some of the biggest predictors of outcome, independent of almost everything else. They often don't seem to be well understood, or at least clearly defined, to family members either.

They are a mix of function, appetite, medical morbidity, resilience, and emotional and mental health. I don't think families recognize frailty as the gestalt it is because it often creeps up on everyone. It's making an occasional meal for a family member when she always did it herself, helping her get up, or buying groceries. It's not a lab value, it's not an age, it's not a problem list, although these often run together. But frailty defined Nana's last year.

It was also why I knew that moving her into assisted living meant she would get worse, and I knew it was the beginning of the end when she broke her hip again. It wasn't the facility that dictated her death; it was that her function was so poor that she finally needed a facility. It wasn't that hip surgery is a big deal (of surgeries requiring anesthesia); it was that she was going to have a hard time with everything that goes with it: surgical, caregiver, and hospitalization stress, pain medicine delirium, nosocomial infections, iatrogenesis.

Nana was a fighter—you can't be a widow in your home for 30 years without being one—but I got scared when I talked to her 18 hours after she left recovery. She sounded delirious and confused, slurring her words. It wasn't a good sign.

We were all so surprised by how quickly it happened. Apparently she was telling the anesthesiologist pre-op, “Let's get this show on the road,” but the next day she wasn't eating or drinking and no one could make her. A week later, she was gone.

I was expecting the sadness, of course, but I wasn't expecting the guilt. Her children felt it the most, but I felt like I should have called and visited more, and that is something I can't change. Our loved ones hopefully know we love them, but you still think you should have told them so more. None of that guilt is fair, or true, but it pierces just as deeply as if it were. It feels like a stab to the heart that this is how we humans learn these lessons. I was fortunate enough to be home for my birthday, and it was one of the best presents to hold her hand, tell her how much she was loved, and say goodbye.

It'll be very hard the next time an old woman rolls into the ED looking anything like Nana, but hopefully through her memory I'll be a better physician for the patient and her family—a better listener, a little less rushed, and spend a little more time in this crazy specialty for the expression of love.

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