A Story of Mrs. B. - Wouldn't a loved one have deserved better?

2014
Dubé, Nicholas

This is a story of Mrs. B., whom I was blessed to meet in a busy emergency department a few years ago as a third-year medical student.

Mrs. B. is just the kind of lady you could write a story about. She comes from a time that cultivated meekness in women, but somehow emerged a matriarch - not only of her family, but of all those around her.

In her mid-70s, Mrs. B. was living the independent life of a weathered pine tree on the shores of Georgian Bay. As a widow and long-distance grandmother, she now had time to prepare instructions regarding not only her weekly routine, but even those hypothetical, challenging situations a woman of her wisdom sometimes dares to anticipate.

Mrs. B. was certain to have savoured the nectar of all her life’s flowers and she did not want to find herself painstakingly searching for more in a feeble body or with a hazy mind. She knew pain all too well, taking morphine twice daily for some respite from her aches. As such, she opted not only against CPR and shocks, but also against having any kind of tube put in her mouth or nose. Other, less invasive measures that could preserve her quality of life, she condoned. And Mrs. B. wasn’t one to keep this kind of thing to herself; her whole family was well instructed in her wishes.

So when she had her first stroke one fateful Christmas Eve, things happened a bit differently than with other patients. Entirely paralysed on her left side and only able to pull her leaden tongue along during speech with bull-headed determination, the doctors were concerned that she couldn’t eat or drink safely. In the hope of appeasing their concerns, she had her swallowing assessed. When the doctors’ fears were confirmed, Mrs. B., supported by her son, had some more convincing to do: yes, she understood very well that she could choke and die if she didn’t follow their advice, but could someone please bring her a glass of water!

After the stroke, Mrs. B. needed some help at home, but her eating and speaking improved steadily and her weakness completely resolved. She regained enough strength to start walking to the bathroom alone and just as everyone’s blood pressure was returning to normal, she was hit by a second stroke.

Two months after the first, this one was even bigger: not only was her whole left side paralysed, but she couldn’t let out a single sound and her eyes seemed stuck deviated to the right. But Mrs. B. didn’t need her voice to give orders. To a medical student with the time to decipher her laboured and frustrated movements, it was clear that she expected things to go exactly as they had before - just as clear as her gestured request for the morning dose of morphine she had been unable to take. Despite her loss of speech, Mrs. B.’s comprehension was intact. Again, her son, was there to support her.

Having had a choking spell when given to drink before arriving at the hospital, Mrs. B.’s son thought she would benefit from a swallowing assessment again, just to gauge the extent of her difficulty. Would it be more agonising for her to try to swallow than it would be for her to stop eating and drinking completely?

And that’s when things start to look like blurry action photos from a football match to me. Although apparently nothing could be done for Mrs. B. with regards to her stroke as she had been found paralysed in her bed that morning, people were coming and going, taking blood, putting in a catheter, pricking her fingers, starting IV’s. She also went for a CT scan, and shortly after, a new young doctor came to see her. He would be taking over her care. He had spoken to the nurse and was aware of her advance directives, but unfortunately a swallowing assessment would be impossible to do because she was mute. As such, she would need a feeding tube as a temporary measure until her situation improved.

Mrs. B. put up a fight as best she could with her one frail arm and pursed lips, but in vain.

When I later came to check in on her, she snubbed me: having clearly understood her wishes, I was in part responsible for having allowed the NG tube to be put in. Had I expected her to stand up for herself? The support worker there consoled me explaining that she herself and Mrs. B.’s son had both been given the same cold shoulder. But Mrs. B. was right: she had deserved better.

Of course, she had the right to refuse an NG and that request ought to have been respected, but to take things one step further let me ask: What else could we have done for this high-spirited woman who wished to live life to its fullest and then move on? How would you have wanted things done if she were your loved one?

I believe we should have offered her thrombolysis. It had been 12 hours since she had last been seen at her baseline, so The Guidelines would emphatically state that the risks outweigh the benefits, but who are They to decide? I am nearly certain that if we had taken the extra time to (learn and) thoroughly discuss her possible prognoses with and without thrombolysis, had we dared to delve into the realms of recovery, death and disability, Mrs. B. and her son would have preferred to test fate. She had already made it explicitly clear that disability was a worse outcome than death for her.

To me, Mrs. B. is a reminder that no matter how strong the recommendation for a given practice, the evidence is only ever for an outcome and not for the practice. As for the value of the outcome, who are we to assume or to judge? Evidence-based medicine always begins with a story.

Wouldn’t a loved one have deserved better?

Theme: Death and Dying | Décès et le mourir
Theme: Health Care Delivery | Prestation des soins de santé
Theme: Patients | Patients

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.

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