wish, worry, wonder

There’s a palliative care communication technique called Wish, Worry, Wonder. It’s a way to broach difficult topics with empathy. For example, if you think the patient is unsafe at home, you might say, “I wish we could fix this weakness you are experiencing. I worry about you falling and having even more pain. I wonder how you would feel about a walker (or a commode, or a bed in the hospice, etc.)” I’ve used this technique a few times and find it helpful to ease into an uncomfortable discussion.

I had a patient a few years ago who was in hospital for acute care–possibly pneumonia, I don’t recall– but he had an underlying cancer. Lying in hospital for two weeks he’d lost a lot of muscle mass and needed some time to get stronger. His active medical management was finished, and he was feeling better, despite his underlying cancer. He was clear about his Do Not Resuscitate order.
     “I want to go home,” he said, “but no tubes for me. No machines or shocks. If it’s my time, it’s my time.” This hospitalization was during one of the COVID waves, so he didn’t have any family with him, and other than daily physiotherapy was pretty much on his own in his room.
     The nurse asked me to see him urgently one day, very upset. The patient wasn’t responding to her. His vital signs were still reasonable, and he was awake, but wouldn’t talk or move. As always, my mind went to many diagnoses as I walked to his room: low blood sugar. Too much pain medication. A stroke. A blood clot. He was, indeed, awake, or at least his eyes were open. He didn’t respond to voice or pain. He took gasping breaths we call agonal breathing: end-of-life breathing. The nurse asked for orders, and I decided to check for a reversible cause, though I knew it was futile. I asked for a blood sugar level, an EKG, and went to call the family to come right away.
     “He may not last the hour. Come right now, have somebody else drive.” Only one visitor was allowed; I told the four family members I’d ask security to let them bypass the COVID screening, they should go straight to his room, not touch anything, wear masks.
     The blood sugar was normal. The EKG showed a slow heart rate, which I knew already. When I went back to assess him, he had died.
     He knew he would die; if not that day, then sometime in the next few months, because of his terminal-stage cancer. Perhaps a slow, lingering death. Perhaps pain, nausea, falls, confusion. Perhaps, he was more comfortable with the possibility of his death than I was.
  
     I wish, instead of doing the tests, I had simply stayed with him. Even though I had to wear a gown and mask and face shield and gloves. Even if he was unable to hear me.
     I worry, that my need to “be the doctor” sometimes surpasses my basic human instinct to be present, to provide comfort only, without any other intervention.
     I wonder if he felt afraid, as he died alone.