Mr. H. was our last admission of the day. His son and two daughters brought him into the hospital late at night. He was a thin African-American man in his early 70s, with neat, short, wiry gray hair and a matching mustache.

He said little, letting his two daughters do the talking. They explained that they didn't know what exactly prompted them to bring him in, but they had a feeling he wasn't doing too well. They filled me in on the rest of his history: severe heart failure, recent loss of energy, increasing difficulty breathing and requiring higher and higher doses of oxygen at home.

Mr. H.'s son, a muscular man of about 40, didn't say a word.

I asked Mr. H. what his code status was. If he stopped breathing, did he want us to intubate him, attach the ventilator, and keep him on life support? Before he could reply, his son interjected, distraught. "I don't want to hear that!"

He opened the curtain separating his dad's bed from the rest of the emergency room and walked off.

After a brief silence, I asked again, and Mr. H. shook his head defiantly: "No!"

His daughters both nodded in agreement. The younger one elaborated: "He's said this for a long time: when it's my time, it's my time. No chest compressions, no intubations, no shocks, no life support."

I jotted down that he would be DNR/DNI.

After finishing the interview, I went to head back to my team room, but before I could, I was stopped by Mr. H.'s eldest daughter. "Our brother doesn't want to really know any of the specifics. He just — would rather not know."

LATER THAT night, I logged on to the EMR to review Mr. H.'s chart. The notes painted a picture of steady decline.

The heart has two chambers, one that pumps deoxygenated blood to the lungs, and one that pumps oxygenated blood to the rest of the body. Both of Mr. H.'s chambers were severely weakened.

This created a vicious cycle: The heart is unable to deliver blood to the body, but the body senses this and raises blood pressure. The heart then has to pump harder against a higher pressure, causing it to enlargen and weaken even further.

The blood that remains in the heart backs up into the lungs, causing pulmonary edema. The fluid buildup can get so bad that people develop orthopnea — the inability to lie flat.

Mr. H. was already on maximum doses of all the right medications, so I increased his diuretic dose, cranked up his oxygen and made a note to call cardiology in the morning to address if anything else could be done.

Then I went home.

THE NEXT morning, the covering overnight resident gave me a distinct look when I walked in to receive checkout on my patients.

"Mr. H.," he said, shaking his head.

"Oh, God," I answered. "What happened?"

"He's real uncomfortable. I've been getting paged all night. His oxygen levels are dropping, but he's refusing everything except for a nasal cannula."

When I entered the room, I saw that Mr. H.'s oxygen saturation was too low. His son and two daughters looked on anxiously. I called respiratory therapy to get the BIPAP machine, which pushes oxygenated air into the lungs forcefully. It's very uncomfortable, but it's effective.

After a few minutes on BIPAP, his oxygen saturation increased. I walked out, called cardiology and told them to come urgently. But before I could do anything else, a nurse was knocking on the team room door. "Doctor, his sats are dropping again."

Mr. H. had thrown off the BIPAP mask. It hissed oxygen unceremoniously from the floor, writhing and dangling from thick plastic tubing connected to the machine. He shook his head, furrowed his brow and looked up at me. "I can't breathe with this goddamn mask!"

His saturation level was now in the 70s. I went to reconnect the BIPAP mask, but he refused, so I grabbed the nasal cannula again and reconnected it, which he allowed. His oxygen level rose, but not enough.

Cardiology arrived to examine him and ask a few questions, but they had the same dawning realization that I had. A few minutes later, they were talking with me outside of the room. "This is completely end stage. His pulmonary pressures are in the 90s, and we're not going to be able to oxygenate him."

"We'd recommend palliative care at this point."

I went back into the room. Mr. H. was taking loud, deep breaths, using muscles in his neck and abdomen to help his diaphragm. Things were moving quickly. I pulled up chairs, and we sat in a circle around his bed. "I'd like to talk to everyone about where we stand right now."

His son's face darkened once again. He stood up and headed for the door.

His sisters gave him a stern look, but let him go. I continued: "Your dad has untreatable, end-stage heart failure. Unfortunately, we've run out of options. I've just spoken with the specialists, and we all agree that the best thing to do right now is to make your dad as comfortable as possible. No more sticking him for blood draws. Pain meds to make him breathe easier. Disconnecting the monitors."

"How much longer do you think he has?" the older daughter asked.

"Hours to days," I said.

She nodded and began to cry. Her younger sister put her arm around her.

BUT I noticed out of the corner of my eye that the son was now at the very edge of the door frame, listening in. Mr. H.'s older daughter spoke up again: "Can you give us some time to think about this?"

"Of course," I said, and walked towards the door, where his son was waiting.

He walked up to me, then motioned with his head towards back in the room. He took a deep breath. "What's — what's going on?" he said.

"Your dad is very sick," I said. "He's not getting enough oxygen. He's DNR/DNI, so we can't intubate him, and he is not tolerating BIPAP. He's dying. I'd like to make him as comfortable as possible in the time that he has left."

I paused, letting it sink in. He started pacing, then stopped. He looked at me again, then peered back into the room. Finally, after giving me an imperceptibly small nod, he walked in to join his sisters.

After a few minutes, the three siblings walked out of the room together. They agreed with comfort care, and within minutes Mr. H. was on morphine and breathing easier. I called our palliative care specialists and a pastor. We unhooked the oxygen monitor.

Seeing palliative care as a victory would have been unthinkable for me just a few years ago. You go to medical school thinking you can figure out ways to save people, not usher them toward death.

But there are some people we can't fix, no matter what lab tests or imaging or drugs we order. For them, palliative care is the right thing to do.

The inevitability of it is still scary, though, and I spent the rest of the morning wondering how Mr. H.'s son would react to his dad's fate.

Around noon, I got a call from my intern. Mr. H. had passed.

I went back to the room. His son was at the bedside, holding his dad's hand and looking deeply into his eyes for the last time.

He turned to me. "It was his time to go," he said. "I saw it. I saw him take one last deep breath. His eyes got real big, and he looked at me, and it was done."

Benjamin Gold, MD (@bengoldmd), is a third-year internal medicine resident at Baylor College of Medicine. He also is a musician and blogs about the extraordinary circumstances his patients face.



Bookmark Gray Matters. It has two chambers, one that pumps deoxygenated blood to the lungs, and one that pumps oxygenated blood to the rest of the body.

