I knew her from several other hospitalizations, all for drug abuse-related medical problems: MRSA abscesses, hepatic encephalopathy, opioid withdrawal. This time she was hospitalized with massive ascites. Her belly was twice the size of the rest of her body and her eyes had the sunken, pinched look liver disease patients have at the end of their lives. She was only a few years older than me.
She'd declined referral to hospice but said "The most important thing to me is that I'm comfortable." She still suffered from pain at an old wound site, and now the stretching of her belly created a dull, constant throbbing which kept her awake at night. She was asking me for an increase in her opioid pain medicines to manage these symptoms.
"I'm glad we're talking about what you want," I said. "And I really want you to be comfortable and have good days, because I have to be honest with you: it is very likely you won't live to see the next year. Your liver is really bad, and in my experience, people who start to have this problem with fluid filling up their belly every few days don't have long to live."
I didn't want to be a voice of doom, but I believed she needed to understand what her next few months held in store: painful recurrent ascites, weekly trips to the ER for paracentesis, regular hospitalizations for encephalopathy or electrolyte disturbances following these procedures. I knew she was holding out hope the Liver Clinic specialists would offer her a lifesaving treatment, but without at least a year of abstinence I knew she wouldn't qualify for liver transplant programs.
She smiled at me bravely. "I hear what you're saying, but with respect, I think the only person who knows when I'm going to die is God. The doctors are experienced and they've helped me a lot, but they said I'd be dead last year." The tone of her voice was sweet rather than defiant, and we actually laughed together.
"I'm with you, sister!" I said in the same, strange tone of tragic jubilance. "I don't know when anyone's life is going to end. That's the Great Mystery of life, isn't it? So if I'm wrong--and I hope I'm wrong--you'll be laughing in my face this time next year. All I'm saying is I want you to be ready, because I want you to have good days for the time you've got left."
Now she had some tears in her eyes, pooling in the sunken recesses of her orbital sockets. My mind flashed through all the times I'd admitted and followed her in the hospital. "We've been through a lot together, haven't we?" I said, squeezing her hand.
"We have!" she agreed, although as she said it I knew I didn't know a fraction of a percent of what she'd gone through. It was one of those lies which has just enough truth to feel right. What I knew to be true was that I really liked her, and I might never see her laughing again.
I prescribed more pain medicines for her to use at home, and I send discharge summaries to her primary doctor and liver specialist in which I described our last conversation, because I hoped they'd be honest with her and generous in managing her symptoms. Then I went on to see the rest of my patients, the image of her wasted face burned in the foreground of my mind, like the shadow left behind on a computer monitor as you close the last image you wanted to see.
Comments