One Tumultuous Night
In February 2017, I spent the night in the emergency room with my friend Andréa as she cared for her Uncle Frank. That night, as Frank moved in and out of consciousness, Andréa struggled to make medical decisions on his behalf, trying to piece together paperwork, information from multiple doctors and hospitals, and distant, fleeting conversations with her uncle to determine what kind of care he might want. Watching my friend go through this experience made me wonder: how did we get here?
Like many healthcare journeys, Frank’s is a long and complicated one. In 2016, he was diagnosed with throat cancer and underwent surgery. That surgery led to serious complications and infections that required round-the-clock care at a skilled nursing facility. By February 2017, Frank had been living and receiving care there for nearly six months.
I was visiting Andréa at her apartment in Manhattan when a care coordinator from that same facility called her cell phone around noon. The coordinator told her they had transferred Frank to the Mount Sinai emergency department. Andréa took a moment to compose herself and then sighed heavily — this was a different hospital than the one that had performed his surgery.
She called the emergency room and then her uncle’s original surgeon. Then she called her sister. Then the doctors at the emergency room. Then the rehab facility. Then his original surgeon. Then Mount Sinai once more. She paced back and forth across the living room as she talked.
Every now and then she sat down and scribbled names and phone numbers in a small notebook. She rustled through papers that sat on her kitchen table until she found the do-not-resuscitate (DNR) order her uncle had signed. She clutched it and the notebook for most of the afternoon.
Frank was somewhat estranged from the family — there was a falling out a long time ago. To make matters more complicated, Andréa’s mother (Frank’s sister) suffers from early-stage dementia. Most days are fine, but stress or sudden events can cause her mother’s memory to worsen. Andréa spends a large amount of time carefully considering the information that reaches her mom — how it gets there and what gets said. That’s why the next call she made was to her sister, to decide if she should take their mom to the hospital and how to break the news.
Frank was fine for the moment but unconscious, so doctors had a lot of questions for Andréa. Can we do this or try that? Have you talked about…? What about…? As Frank’s medical proxy, Andréa was the legally-appointed decision maker authorized to speak on his behalf. Andréa and her uncle weren’t particularly close, but before his throat surgery he had asked and she’d said yes. So, that night, all the decisions fell to her.
A few tense hours passed, and Andréa received another call from the emergency room clerk. They patched her through to Frank’s doctor who told Andréa that Frank’s blood pressure had dropped significantly and, to stabilize him, they had injected him with medication. They asked her permission to put in a central line, a catheter that would continue to deliver the medication directly into his bloodstream.
Andréa stood over her kitchen table and flipped through the DNR order. Her breath was strained and deep, like the weight of her thoughts was somehow putting pressure on her lungs. Eventually she said, “I don’t know.” She read out loud the part of the DNR order that said Frank did not want any excessive measures taken and she asked the doctor, “Does this count as an excessive measure? I’m not sure what he would want here.”
He didn’t give her an answer but instead said, “It’s not something I can answer for you.” She pressed him for more, clearly shaken.
They talked for a few more minutes and, finally, she revealed that she was struggling because just a few weeks ago, when she visited Frank in the skilled nursing facility, he’d said, “I wish it were easier to die.” She hadn’t asked him for more details and he hadn’t offered, but in this moment she was hesitating because the medical language was vague and unclear and her knowledge of what to do wasn’t strong enough to make a decision.
Andréa asked if she had time to come up to the hospital — a 20-minute cab ride. “Yes,” the doctor said, so we hopped in a cab and rode in silence the whole way, broken only once for Andréa to say to me, “Thank you for coming.”
We got out on 101st and Madison Avenue in East Harlem. When we approached the emergency entrance, Andréa stopped short of the door, made the sign of the cross, and said a short prayer. Then, we walked in.
In the time it had taken us to get to the hospital, Frank had woken up and was responsive enough to discuss what was happening. In the end, he told the doctors he wanted the central line.
Frank’s condition was touch-and-go the next day and the day after that. Andréa went back to the hospital, coordinated her parents’ visit, and wrestled with tough medical decisions night after night. About a week later, Frank died. When Andréa called me, she said that she was both sad and relieved. The whole process had been incredibly stressful and, though she grieved, she was happy to know he wasn’t suffering anymore.
More to the Story
I walked away from my time with Andréa thinking there’s something here that as a society we’re not doing well. Being responsible for the well-being of a loved one is always going to be hard, but some parts of the situation felt unnecessarily difficult and hard to navigate — as if you were trying to cross a bridge over a deep ravine, but most of the planks were missing.
Andréa’s experience, and knowing that there are countless others like hers, inspired our team to found Canopy. We have dedicated ourselves to helping people from all walks of life better prepare for their journey through healthcare by supporting the conversation and decisions around it and bringing clarity to difficult situations.
In the last year, we have talked to many people with similar experiences navigating modern medicine and making tough calls with their families. In fact, it seems like every time we tell people what we’re doing, they have a story.
One man told us about just how difficult it can be to get family members to engage in conversation:
“My father has been diagnosed with terminal cancer. Even with the drug trials, we’re looking at under 2 years left. He’s not doing well with dealing with it and has consistently denied seeing a counselor who might help him start this conversation.”
Another woman had similar concerns.
“I’ve tried to talk to my dad about this in the past, and he’s been extremely reluctant to engage aside from telling me, ’You know what I’d want in X situation, and you can decide.’”
One woman spoke about the emotional toll navigating decisions takes and about how small acts of kindness can help make the experience better.
“I am only 58 but I have a lot of experience in this area. I had to remove my step-daughter (23 years old), my father, and my late-husband from life support. All three experiences were heart wrenching. These experiences were done in two different hospital settings. The way in which they were handled were very different. One experience stands out as being handled the best by palliative care, the hospital, nursing staff/physicians. The other two could have been better. It truly is the little things.”
Another man spoke about his struggles with medical providers who were uncomfortable talking about death and dying.
“I have taken care of four close family members at end of life. [My] biggest frustration was with the health professionals who had problems with addressing the topic — from avoidance of discussion and actually care even.”
And yet another spoke about the peace that came with a message from his wife’s brother.
“My brother-in-law was in a coma at a hospital emergency room. He had written a letter to my wife (which a friend brought to us ) saying to not resuscitate him as he was dying of AIDS. The letter eased the family decision to not resuscitate him.”
Each story makes my heart ache, but we need to hear them.
What’s your story?
Healthcare is a journey we all take. At Canopy, we want to help make that journey and the conversations around it better. We would like to hear how you’ve had (or not had) conversations about healthcare decisions, prepared for your own or a loved one’s healthcare journey, and the medical complexity you have experienced as a family, medical provider, or patient.
If you’re willing to share in the comments, please do. If you’d like to send me an email instead, I’m available anytime at firstname.lastname@example.org.
Canopy is a health technology company dedicated to helping people from all walks of life better prepare to manage the difficulties of modern medicine. Right now, we’re building digital tools to help manage advance care planning conversations. You can find us online at canopy.tools.
If you’d like to hear more from us, sign up for our monthly newsletter.