the will to live

She came to my Internal Medicine team, carried by her daughter to the hospital weighing all of 87 pounds. Her wiry gray hair stuck out bush-like from her head and her petite facial features hinted at an elegance that likely flourished in her youth now gracefully aging her as she continued through her octogenarian years.  She was mentally altered, her daughter said, not walking on her own like she had previously been able to do, and eating very little.

We did our tests and found some things that needed intervention. She needed a tube placed to bypass her inadequate swallow so she could receive feeds directly supplied to the stomach and we felt better about decreasing her aspiration risk while simultaneously improving her nutritional status. She was improving, or so the vital signs and laboratory tests indicated; her face, shadowy and often confused, however, did not equal such objective data. The next decisions to direct goals of care required considering surgical intervention, which would need to be preceded by a prolonged recovery period of physical therapy and intense nutrition to reverse the functional decline and malnourished status.

The sexy part of medicine lies in the capacity of impressive interventions. We continue to invent and create and develop technologies to replace heart valves and use robots for surgery and design drugs so specific as to target one gene in one person for their specific form of cancer. Such dazzling scientific interventions meet the sublimity of the human will at the chiasm of medicine where often such a will cannot be overpowered.

Our lovely octogenarian had lost her will to live. Having graduated at the age of 19 from college, a mother of two and married to a handsome Navy officer, she ran her home with precision, grace and generosity. So capable was she of anything and now she could not stand at the edge of the bed herself. With heavy, but wise, hearts the family opted to not pursue the extravagant interventions that were needed to fix her ailing body; rather they opted for her comfort. We removed the nasogastric tube and I told her she was going home. Her face brightened for the first time in two weeks. She was going home.

She is the fourth patient I have made comfort care this week. Walking with families through the difficult conversation and the realization that their loved one has nothing left to hold on to life and thus comes the completion of the cycle. In our cultural effort to ward of sadness and fear and loss we do more and think less. We struggle with letting death be an acceptable alternative to the more risky and more dazzling alternative of doing more. But in the end, regardless of what we have the capacity of doing, the will speaks for itself and cannot be deterred. The resilience and the mystery of being human with its inevitable mortality will supersede any sparkly alternative we create.

While a large part of my role may be tapping into the options available, the wisdom of doctoring is affirming those times when the will to live has gone. In that moment my best intervention is holding her outstretched hand and letting her go home.