What Mrs. T Taught Me

Pawina Subedi, MD

It was August of my intern year when I first met with Mrs. T, a pleasant young female in her mid-50s with a history of alcohol use. She had been admitted overnight for severe abdominal pain. An upper GI endoscopy confirmed alcoholic gastritis. As she began feeling better, we started planning for her discharge. I discussed her results and my concerns about the effect alcohol was having on her health. She said I had given her a lot to think about and that she would avail herself of the provided resources when she was ready.

It was about 7 a.m. on a cold December morning in the medical ICU when I met Mrs. T again. She had developed symptomatic hyponatremia, in part resulting from continued alcohol use. I was disappointed, but not terribly surprised. I shared my previous experience taking care of her with my ICU team. As her hyponatremia improved, she was transferred to the medical floor and subsequently discharged in stable condition after three days.

About five months later I was conducting sign-out for a patient with cirrhosis and severe C. diff colitis. Yes, Mrs. T had returned. When, how and why had she developed cirrhosis? As I entered her room, I was stunned to see a now icteric Mrs. T with generalized edema, swollen parotids, and a clearly altered mental status in the throes of hepatic encephalopathy. It turned out that she had been admitted three times since our last encounter in the MICU. She had continued to drink and was no longer a candidate for liver transplant. Since her disease process was advanced and she did not have capacity for medical decision making, the palliative care team came onboard. We contacted her healthcare proxy — her best friend, Ms. V — who told us she had not seen or heard from Mrs. T in the past three months despite multiple attempts to get in touch. I was not prepared for what Ms. V had to say next. It turns out Mrs. T had been battling depression for a few years, but it had worsened over the months as marital turmoil had resurfaced. She had taken to heavy drinking as a coping mechanism. Her hospitalization in August had served as a wakeup call for Mrs. T and she had been determined to cut down on her drinking. Her father, who was her pillar of strength, had been helping her through this. Things spiraled downward quickly after his sudden death from a heart attack and she went back to drinking. The last time Ms. V had seen her best friend was during her father’s funeral. Things got even worse after her divorce was finalized, and she lost the custody of her three children. She had become homeless thereafter and later moved in with a friend. I could not believe how much she had been through. Her current medical issues seemed to be just the tip of the iceberg. It felt like we were putting a Band Aid on a bullet hole, so to speak. It struck me how little I really knew about Mrs. T, how unaware I was of her struggles and how in my ignorance I had failed to see why her habits remained as so. Ms. V told us that the Mrs. T she knew, her best friend, would not have wanted anything heroic and her code status was changed to DNR/DNI. I asked Ms. V if Mrs. T would have wanted us to contact her family or friends. Perhaps they would want to know that Mrs. T was in the hospital. I was unable to find any phone numbers in the system apart from hers. But Ms. V said that her family did not want anything to do with her nor did her friends. I do not remember much about what I did that afternoon after our meeting concluded. I must have reached home somehow. I struggled trying to fall asleep that night as a myriad of thoughts occupied my mind. Had I known what she was going through, could I have intervened somehow? Would things have turned out any differently if all those times she had been admitted to the hospital, I had taken care of her and learned more about her? Maybe I could have asked psychiatry to see her. Maybe I could have requested our social worker to help with her disposition. Or, maybe — just maybe — she would have confided in me about what was going on in her life. I felt a very strong sense of guilt, as if I had failed her. How could I have not seen this coming? How could I have not anticipated this? As medical professionals, we are trained to save lives. Then, how did we fail her? How did I not see this sooner? Even with all these modern medicines and interventions, why is there still so little she could be offered? How could we be so helpless? I could not keep myself from imagining a scenario in which some intervention had happened and the outcome was different.

Mrs. T went on to develop progressive renal failure and was discharged to home with hospice. To this day, I feel a strange sensation in my chest each time I pass by the room that she last occupied. Strangely, perhaps by some unknown forces, none of the patients that I have taken care of since has been assigned that room. But I take some solace in thinking that she was comfortable and with her beloved friend in the days that followed. Whenever I am faced with a patient’s demise, I feel like a part of me goes with them. Death is the inevitable truth that no one wants to necessarily think about. Working in the medical field, especially with the pandemic, I have come to respect the role of palliative care — the team faced with the daily challenges of providing comfort near the end of life. It was Mrs. T who introduced me to this indispensable medical field and for this I am forever grateful to her.

Pawina Subedi, MD, PGY3 Internal Medicine Residency, St. Vincent Hospital