End-stage COPD (chronic obstructive pulmonary disease) due to lung damage from smoking had been his problem for the past decade. Lung tissue destroyed by toxic exposure leading to severe shortness of breath. He needed oxygen at all times, and could only at best mobilise short distances. Life had become a struggle, and just when he thought things couldn’t worsen, they did.
He was in really bad shape when he came in on Friday, he was only semi-conscious and could not respond to my questions. His wife and son, who were his main caregivers at home, looked exhausted. He looked terrible, blue lips and tongue, breathing rapidly, short, shallow breaths, with only a small amount of chest movement. I had not seen him so unwell before, which really concerned me.
Using all my clinical skills and experience, I really thought that he was dying, that he would die within the next hours. That he might last only days, and might never fully wake up again. I gently conveyed this news to the family. That I thought this might be the end of his life. They took it well, he had been unwell a long time, and had been close to death many times in the past.
I prepared his medication chart for end of life care. I wanted to cover the five common symptoms that occur at the end of life; pain, breathlessness, nausea, agitation/confusion, respiratory secretions. Anticipatory prescribing for a dying person is done, in order to cover the things that occur commonly during their last hours to days of life. Aiming for comfort more than anything else, we started him on syringe driver medications. This would mean a continuous infusion of symptom control medications to keep him calm and comfortable for whatever time was left. I left that Friday afternoon truly thinking that I would not see my patient alive when I returned after the weekend.
I returned to the hospice on Saturday evening as we were holding a live fundraising concert starring local musicians. I had brought my family out including my young children, as it was a real family event. Right before the performers were to start we were all joined by another family of three. A young man was pushing a wheelchair, where an older man sat, they were accompanied by a smiling woman. They all waved and smiled at me, and were bemused by the shocked look on my face. My patient who I had thought was imminently dying when he came in, had arrived for the concert. He winked at me as he was wheeled in front of me.
Some things I don’t mind being wrong about. Over the next three years whenever I met our patient or his wife, they would always tell the story about the look on my face when I saw him at the concert.