Reflections from the Grady wards: Don't cry over spilled milk (at least no more than two tears)

*patient name and minor identifying details changed (although written with patient's permission.)

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One of our patients on the inpatient service at Grady has multiple organs failing secondary to a hard life of drug use and alcohol dependence. Even with the most aggressive management, his overall prognosis is not good. Let me not sugar-coat it--he is dying. Not necessarily in the next few hours or days, but the problems he has are severe and they aren't reversible. The little picture of his hospitalization focused on daily fights against kidney malfunction and fluid filled lungs and shortness of breath. We talked about it on rounds until we were blue in the face--

"Do you think increasing the diuretic will help with the fluid? Or will it make his kidneys worse?"

"Well, yesterday it helped. Today it seems to have made his kidneys worse."

"Sigh."

The big picture we didn't discuss so much. It involved uncomfortable words like "refractory" and "hospice" and "death." On this particular day, I knew it was time for us to go there. I said to the team on rounds: "As much as we don't want to, we have to address the big picture." Nick, the intern caring for him, nodded in agreement--he knew this statement was code for "you have to address the big picture."

Mr. Miller was a middle-aged, self proclaimed "old playa the streets." He had no problem admitting to his abuse of illicit substances in the past, and, I think, took pleasure in telling us about his lessons he'd learned along he way. Mr. Miller had pretty decent insight about the little picture of his hospitalization--heart failure and kidney failure leading to fluid overload--but the big picture, I wasn't so sure about. When we finished examining him and discussing the day's plans, the time had come for us to talk about his overall prognosis (a.k.a. "big picture.") Nick knelt down and rested his elbows on his knees. He softened his voice and gently explained to Mr. Miller that the combination of weak kidneys with a weak heart wasn't good. "It's like a vicious cycle . . . .the treatment for the fluid buildup hurts your kidneys, and letting the fluid buildup can be life threatening. We're trying to avoid dialysis, but even with that, your organs are still very sick."

Mr. Miller just looked at him calmly without speaking. In fact, let me be even more specific: He was in the bed leaned on one elbow comfortably while reaching over the top of his head scratching his scalp with the other. He seemed to be concentrating far more on trying to suck some trapped food from between his teeth and the nagging itch atop his head than anything his young doctor was saying. Hmm, maybe that insight isn't so decent after all.

"Sir. . . .I want to talk to you about your feelings about. . . well. . . what you might want if your heart was to stop beating or you were to stop breathing." Nick swallowed hard and looked at Mr. Miller earnestly. Awww, shoot. What will he say? Will he be upset? Accuse us of giving up on him? Challenge us to trust in God, just as he was doing? It was hard to tell; I knew the best plan was to just wait and see.

Mr. Miller yawned wide like a lion on the Savannah. He reached over his head to do the signature scratch one more time and then rested his eyes directly on Nick. The whole team stood quietly around his bed casting glances between kneeling Nick, each other, and of course, Mr. Miller. I found my mind wandering. . . .despite my efforts not to, I eventually starting trying to predict what would come next. I imagined something like:

"Y'all doctors sometimes thank y'all have all the answers, but I know that y'all don't have the final word. Only my God does."

I could handle that statement, and even knew what I might say in response: "You're right, sir. In no way are we suggesting that our explanations go beyond what is divine. It is just our responsibility to share with you the medical information that we have available to us based upon what we often see under these circumstances."

Or maybe his approach would be slightly different, and instead he might say with a twinkle in his eye:

"I'm fine--I don't know what y'all talking about! If my heart stop, bring me back, man. I got a lotta years aheada me."

To that, someone on the team might launch into a soliloquy about how subjecting him to an aggressive resuscitation could create unnecessary hardship for him as well as his loved ones. If the intern grew uncomfortable, I might step in and add that one of our goals is to always try to help our patients with conditions that bring them near the end-of-life achieve a pain-free death with dignity. But from looking at Mr. Miller, it wasn't clear what he'd say next.

Nick shifted his weight on his toes as he continued peering up at Mr. Miller from his stooped down bedside position. My knees hurt for Nick the moment he assumed that pose--these conversations are usually not quick ones. Mr. Miller snorted loudly, gathering something his throat and gestured for someone to hand him the emesis (vomit) basin. Nick gave his knees mercy, quickly stood, and obliged his request. We continued to wait respectfully as Mr. Miller hocked up a few more mouthfuls of phlegm and, without the least hint of embarrassment, expectorated into the plastic half moon in his hand. After placing it to the side, he propped himself back up on that elbow, sucked his teeth a few more times, and yawned once more. Oh lawd. What is he about to say? Did he hear Nick? Is he bored and ignoring us? What?

If I haven't learned anything at Grady, I have learned this--you cannot, I repeat, cannot predict what will come from somebody's mouth at any given time (that includes both words and bodily fluids.) Finally, Mr. Miller cleared his throat, and gave a small shrug. He spread his fingers apart for emphasis before he spoke.

"Look hear, doc," he started while gazing into Nick's sincerely concerned eyes, "I done had a hard life, knowwhatumsayin? But it's been a good life, though. I done some thangs that's been hard on my body, and I know that, knowwhatumsayin'?" I was mesmerized by the way he placed his own special punctuation to every few syllables. "Look here, I understand that the damage is done, and I'm okay with that. I done made peace with my God, knowwhatumsayin', and I ain't gon' sit here pretending like all the sh#% I've done to my body ain't take a toll on it."

"Yes, sir," Nick replied softly. I hung onto every word of Mr. Miller's monologue.

He went on. "We got a little saying that we use around the way, doc. 'Two tears in a bucket, motha f$%k it!' That mean, no needa you cryin' over somethin' that's already done, knowwhatumsayin? Look here, I know what's up. I do. Don't be comin' to me every day with all that slow sangin' and flower brangin'. Man, if my time comes or my number is up, man, let me go. Don't do all that stuff to me if it ain't gon' help matters."

Wow. Mr. Miller broke it all the way down in less than thirty seconds. Nick could have kept kneeling for that. Though quite colorful, Mr. Miller's explanation of his situation revealed that his insight was not just "pretty decent", but excellent--and not just on the little picture, either. He knew "what was up" with the big picture, too. I subconsciously offered him an apology for thinking otherwise.

I have to say, I particularly liked his delivery of the "tears in a bucket" statement, although (should I be telling you this?) it wasn't the first time I'd heard it (or even the second time. . . .should I be telling you that?) That said, it's still fair to say, even though I've already admittedly been exposed to the language of a few other "old playas", it was indeed my first time hearing that in a hospital, which gave it a whole new meaning.

Here's what I learned from Mr. Miller that day:

1. Never underestimate your patient's ability to understand what is going on. Never.
2. Wait long enough for your patient to hock up loogeys before interrupting them--you just might learn something.
3. Be okay with your patient expressing things in their own words, even if they aren't ones you'd choose. Again, you just might learn something.
4. Remember their words--they can be pretty profound sometimes. ("Slow sangin' and flower brangin?" come on, man!)
5. Worrying over spilled milk gets you no where, or as Mr. Miller and "playas" like him would say, "Two tears in a bucket. . ."

***

Turns out that Mr. Miller is doing a lot better right now. Hmmm. Perhaps his philosophy on spilled milk is one that we should all consider adopting. It might help us all avoid any negative self-fulfilled prophecies . . . .or at least enjoy ourselves while waiting for whatever our futures may hold. :)