2nd Place 2022 GHHS Essay Contest Winner
By Erin NaPier
A petite 89-year-old woman presented to the hospital with an advanced heart failure exacerbation. Shortly after I introduced myself, I realized that she had difficulty hearing me. With my voice hovering near a yell, I inquired, “MRS. T, CAN YOU HEAR ME?” She responded in an equally loud voice, “SOMETIMES,” and smiled. Lip reading can be a powerful tool, but the ubiquity of masks made it useless in the Covid hospital setting.
I placed my stethoscope on her chest and listened intently. It’s very frustrating when you can’t hear these things you’re supposed to hear. As I stood up, Mrs. T asked with a twinkle, “AM I DEAD YET? IS THERE ANYTHING STILL BEATING IN THERE?” Her nurse and I, initially mortified, joined Mrs. T in a hearty laugh.
Mrs. T had extensive swelling in her extremities, severe shortness of breath, a cough, signs of kidney under perfusion, and a faulty heart valve, but she was still cheerful. Her mood and affect seemed independent of her physical ailments. She commented that she had lived a “WONDERFUL, LONG LIFE” and she was “READY FOR THE LORD TO TAKE ME.”
Each time I asked her how she felt Mrs. T responded, “GOOD,” and smiled back at me. She took rapid short breaths, while her nasal cannula delivered high volumes of oxygen. “ARE YOU HAVING A HARD TIME BREATHING?” “A LITTLE,” she confessed, and continued to smile.
I watched as multiple health care providers tried to communicate with Mrs. T. Most spoke in a loud voice, but I was dubious how much she was hearing. A resident mentioned that the nurses’ station had a device that might help me. I eagerly asked a nurse for help. He dug deep in a drawer and provided a Ziplock bag containing a voice amplifier.
I asked Mrs. T if she wanted to try using the device and she looked puzzled. I put the earphones on my head and motioned to her asking, “DO YOU WANT TO TRY THIS?” She nodded vigorously. I helped position the headphones over her ears and slowly increased the volume as I spoke into the microphone.
“Oh wow! This is wonderful!” She beamed as we talked about her children and grandchildren, her favorite football team, faith, and life outside of the hospital. My own 95-year-old grandmother had been in the hospital recently and her children and grandchildren were prohibited from visiting her due to Covid restrictions. I asked Mrs. T many of the same questions that I would have asked my grandmother.
As I left the clinic, I mentioned to Mrs. T’s nurse that she appreciated the voice amplifier. When I returned that afternoon to check on Mrs. T, a different nurse was initiating a procedure. It was gratifying to see that she was using the voice amplifier too.
Hospitals are isolating, sterile environments, especially during Covid when interactions with loved ones are limited. Mrs. T was undeniably sick, and we were doing everything we could clinically to help her. While the voice amplifier didn’t directly help us to fight her heart failure or the pneumonia that was brewing in the background, it allowed us to communicate more effectively with each other. She could hear us explain procedures, why we changed medications, and why she needed more oxygen. It is difficult to form a therapeutic alliance when one party cannot hear.
Mrs. T’s clinical course soon headed south. She developed a severe white out pneumonia and her oxygen requirements continually increased. She wasn't responding to aggressive antibiotics and eventually needed non-invasive ventilation with a large facemask that covered her nose and mouth. The voice amplifier was powerful, but it couldn’t overcome the roar of the ventilation machine. As Mrs. T’s kidneys shut down, the buildup of toxins in her blood made it difficult for her to think clearly. Her mental status wavered as she faded in and out of wakefulness. She repeatedly reached for the facemask and asked to take it off.
Her advanced directive made it clear that she did not want invasive ventilation with intubation, but it didn’t specify her thoughts on non-invasive ventilation. Mrs. T’s family was conflicted and reluctant to decrease her level of care. Clinically, we did not think a nasal cannula would provide enough oxygen. We shared that she had expressed that she was ready for death if it were her time. Her family agreed that this was consistent with their conversations with her. After further discussions, Mrs. T was scheduled to be discharged to hospice. We honored the wishes of Mrs. T and her family and provided her with a nasal cannula. We removed many of the lines from her body as well as the beeping, humming machines from her room. Anticipating that she might not make it through the night, we paged a Catholic Priest who administered Last Rites. Her family brought in pictures, a yellow blanket from home, an intricate pillow, a bouquet of her favorite flowers and played soft Hawaiian music. She survived the night and many more subsequent nights than we had predicted. She passed away peacefully a few weeks later surrounded by family and friends.
Medical training emphasizes fixing clinical problems with prescriptions and procedures. But understanding our patients and their goals is at the heart of maintaining humanism in healthcare. We must find the means to listen effectively to our patients and treat them the way we would want ourselves or our own grandparents to be treated. Sometimes, we must act as voice amplifiers and advocate for our patients. We did not cure Mrs. T’s heart failure or pneumonia. But I am incredibly proud to have been a small part of the team that helped to shape the experience of Mrs. T and her family during the twilight of her life on Earth.
In loving memory of my Grandmom Bette and Mrs. T, both of whom left this world with dignity, surrounded by loved ones.
