I have been in this position a few times now. To protect confidentiality, the following account is inspired by a number of experiences and does not describe a specific patient.
A young patient, well known to me, was admitted to the hospital once again. She had become severely jaundiced and the cause, as usual, was heavy drinking. Just a month ago she had spent three weeks in hospital being fed via a nasal tube and receiving steroid tablets to calm down the dangerous inflammation in her liver. This time she was even more unwell. Her arms and legs were thin, her abdomen was swollen and she was confused. But, as before, after a few days her strength began to return and the jaundice improved. Her family came in. They tried to convince her to stay at home with them in order watch over her, but she preferred to live in a shared house, with her friends, friends who supplied her with alcohol.
As I left one night I saw her sister walk onto the ward. ‘Pretty stable.’ I told her. We knew that she was unlikely to survive more than six months given the gradual decline in liver function, but the time that she spent outside hospital was satisfactory to her, and not without pleasure, or freedom. We had made every effort to help her recover from alcoholism, but to no avail.
As I drove in one morning I received a phone call to say that she had vomited two pints of blood on the ward. I parked the car and rushed in, knowing that she would need to be admitted to the intensive care unit for resuscitation and an emergency endoscopy. She lay on her side, a puddle of congealing blood extending from her head to her chest on the bed sheet. The floor was sticky with it. She was groaning, but still conscious, fully aware of what was going on. The curtains had been pulled around all the other patients’ beds so that they did not have to witness this terrible scene.
Within fifteen minutes she had been transferred to the intensive care unit and preparations were made to sedate and intubate her. This would allow me to perform an endoscopy without her struggling and moving around. I stood over her and she looked up. I explained what we were planning to do. She said, ‘Doctor, just tell me I’m going to wake up from this.’ I hesitated and said, ‘Yes, we should be able to stop the bleeding and stabilise you, you should be awake in a couple of days.’ An oxygen mask was put over her face and the first sedative was administered.
I had lied to her. I knew her liver was probably not strong enough to sustain her through this massive haemorrhage. Privately I gave her a 10 to 20% chance, at most, of pulling through. A large enough chance to justify aggressive treatment, especially for such a young patient, but a long shot. As the anaesthetist began to insert the endotracheal tube a dark fountain rose up from her mouth and poured onto the already sodden pillow. Twin rivulets of blood fell from her nostrils. Her hair was matted with it.
When I passed the endoscope into her oesophagus all I could see was red. I then inserted a balloon into the stomach to squeeze the engorged vessels from below, but her blood had become too thin and she continued to bleed. I tensed the balloon as much as possible, but over the next two hours she lost more blood and her heart began to fail. The family arrived and I spoke with them. Death was now certain. She died half an hour later. It was no surprise – not to me, not to the nurses, not to the other consultants who looked after her in the past. But I could not forget that one of her last human interactions was with me, when I gave her reassurance that she would survive. I wonder if, as the sedatives kicked in, and the sound and the meaning of my words drifted across her darkening mind, they offered any comfort at all.