Thank you Vin Scully, Part 1
Sunday, Vin Scully, the voice of the Dodgers for 60 years, called his last game from Dodger Stadium. I got included in an email exchange between my dad, his brothers, and his childhood best friend who has taken to writing in his retirement. Keith — the friend wrote a little “thank you Vin Scully” piece and sent it out to us. My dad responded saying he’d never forget Vinny’s voice and replied:
“There will never be anything like him again. Those of us who were fortunate enough to experience him had our lives enriched by it. Not many throughout history have touched so many. He is truly great in the best sense of the word. “It’s a long fly ball into deep right field, it’s going, going, gooooooone!”
Though I am not, personally a baseball fan, I was touched by these comments from my Dad and uncles. However, I happened to have some reason to thank him myself and so I wrote this reply.
Thank you, Vin Scully, Part 2
Yesterday, at the hospital, I had the honor of being someone’s last ever physician. This is a duty and a privilege I don’t take lightly and view as close to the most powerful demonstration of my Hippocratic oath. My patients, and their families, are the beneficiaries of this oath and my profession’s other guiding commandment: Primum Non Nocere; or First, Do No Harm. For whatever reason, when I suddenly lost my mother, I gained a deep, profound understanding of death that has reshaped my approach to being human and to being a physician. All doctors see death; most of us are terrible at dealing with it, the feeling it stirs inside us and this discomfort transmits to discussions with families. My generation has become better at talking about this process and about helping patients and families and patients identify their core values in regard to their remaining lives. Some value quantity of days over quality of days. To me, I thought the obvious, most common choice would be quality over quantity.
Sometimes, however, this is not the case. Occasionally, a patient wants to live to see an important event or milestone. Many times, however, it happens little by little, intervention by intervention. Almost accidentally, someone spends the majority of their last year of life in a hospital, being poked; with tubes inserted in every opening and into the new holes we make to insert more tubes. We doctors can spiral quickly out of control and move into the realm of doing harm — especially specialists, surgeons, and oncologists who have a procedure, experimental treatment, or new drug to offer. This is not due to ill intention; it is due to the difficulty of recognizing that, although we are trained scientists and technicians, these skills are meant to augment our role as healers. At the end of life, we are not to heal the body but to help heal the fears, pain, anxiety, that come when we start to shuffle off this mortal coil.
What then, does this have to do with Vin Scully?
My patient who died early this morning was expected to die on Saturday. He had all the signs, he was not speaking, he had a fixed stare and a death rattle that no one can ever forget once they have heard it. This patient wanted to continue to “fight”; he had not yet accepted that inevitable truth that, for most of us, the time of our death is not ours to choose. Everyone in my hospital knows this man. He’s one of the ones who spent the majority of the last year with us. Last week, I had sent him home Monday, knowing he would be back, and soon. It was Wednesday night. I saw his name on my list of overnight admissions on Thursday morning.
I always see my sickest patients first, therefore I saw him early that morning. He was in the ICU, a tube inserted down his nose into his stomach pumping in a beige liquid that is supposed to provide nutrition to those who are too sick to eat. We call them tube “feeds.” Humans do not receive feeds, we eat meals. He was on a monitor, and on a medication to support his blood pressure — a pressor. When someone needs pressors, they are in cardiovascular collapse; shock, in the vernacular. They are dying. His first pressor was at its maximum level.
He had come far enough to realize that he did not want CPR or to be placed on a respirator (life support). Most people think these are two separate choices, but they actually aren’t; if you need CPR, cardiopulmonary resuscitation, your heart and your lungs have stopped working. You will undergo chest compressions, shocks, intubation and placement on a ventilator. If you are very sick, the likelihood that you will survive this neurologically intact is near zero.
With his pressor maxed, it became my responsibility to remember my oath. I could have placed an IV line directly into his central circulation so that we could add on another pressor, and then another, and another. Typically we’re out of options once the 4th and 5th pressor is needed. A panel of medicines powerful enough to keep a dying heart beating and a collapsing circulatory system delivering blood to vital organs in sufficient quantity to keep them function does damage, it draws blood away from extremities, it forces the heart to work harder than it is capable of. It prolongs the futility of our efforts.
I opened up the curtain to his ICU stall and spoke to my patient and his girlfriend. This was the moment where I had to have the courage to accept and face his imminent death. This is the discussion that often gets us doctors in trouble. Most doctors would have started asking, menu style, what other interventions they would like. I did not offer choices.
I offered the truth: “He’s dying,” I said. “We will not escalate his care any further.”
I’ve seen many colleagues go the other way — start making offers, adding interventions and then the inevitable outcome occurs two weeks later: after the patient, the family, and, honestly, the medical staff have suffered terribly and unnecessarily. I am not the hero of this story however, I wavered a bit — I said we could try the pressors for 24 hours. However horrible it may sound, some of that choice was motivated by my mandate to have high patient satisfaction scores and my motivation to not be sued or accused of murder.
With the support of our palliative care team, I had him placed on comfort measures Friday. Moved to a private room, off pressors, no lab draws, no vital signs. Once someone is on comfort measures (which typically involves Keith’s much coveted morphine drip), my work as a healer changes from focusing on fixing problems and shifts to helping patients and families understand what is happening as the body shuts down; how to maximize comfort, what signs to look for and when to ask for intervention — more morphine for dyspnea, Ativan for agitation or seizure, scopolamine for secretions. Mostly, though, I become a witness and a supportive listener.
It’s impossible to predict how long it will take someone to leave this world, but my general rule is that it takes as long as it does to come into it — 24-48 hours. Saturday was the day, I thought. I saw him and his girlfriend twice that day; I spent an hour or so each visit, hearing stories. Learning about him as a man, not as a patient.
I learned he loved his dog more than anything in the world, that he collected matchbooks, and that he loved American history. And, I learned that he loved the Dodgers. He had already purchased the blue and white jersey he was to be buried in, with the number 99 on it — the year he had met his girlfriend while he was still grieving his newly dead wife. He had his cap, too. And he had written his own obit. He was including a picture of himself holding the dog at the stadium. They often paid for a seat for the dog and took him along to games. He was unconscious, but we think in medicine, (I don’t know if we have proof) that touch, followed by hearing are the last senses to go. So, I touched his chest and bent down and told him it was a pleasure taking care of him and that I would watch his last sunset with him in mind.
Yesterday morning, he was still alive when I got to work. Sometime during the day, someone said something to me about it being Vin Scully’s last day calling games at Dodger stadium. I waited to go see him until I knew the game was on. More family was there, family that did not seem as close and wanted to know lots of technical detail like “at what blood pressure do you worry that someone might be dying.” His girlfriend asked me not to answer, but I told her she wouldn’t mind my answer and looked to the questioner and said, “zero over zero.” I asked why they weren’t watching the game, and suggested that we might want to stream it on the Internet for my patient to hear. I said that maybe he wanted to hear Vin’s last game at the park. The family lit up. Yes! They said, that must be what he was waiting for. We downloaded an app and I ran all over the hospital looking for a plain old radio in case the streaming didn’t work. It had to be radio they said, not TV. Radio was where Vinny shined. Listening to the Vin Scully call Dodger games on the radio was what my patient had done growing up with his dad. And for his girlfriend, she said, “It’s the Mexican way.” I went back to check on them before I left, and told him the same thing I said the night before. When I left, they had a cellphone by his ear, Vin calling the game, the dodgers leading. My patient was “going, going, and now he’s goooone!”
Thank you, Vin Scully, for helping him let go.