Making Promises We Cannot Keep

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Three-quarters of the way through inpatient rounds, my team and I stopped to see our patient, a woman in her 50s who had been given a diagnosis of acute lymphocytic leukemia and had been started on chemotherapy over three weeks earlier. She had been doing well and her blood counts were starting to recover, so she would soon go home.

I walked into her room with my gaggle of team members: two nurse practitioners, a leukemia pharmacist, a pharmacy resident, a medical resident, an oncology fellow. Or was our group a pride? One of the frequent debates we had on rounds was what to call the lot of us.

“How was your night?” I asked our patient, as I eased on to the edge of her bed. Her husband sat in a chair by the window, and I smiled and said hello to him. Behind him the sun had risen, and the Cleveland skyline looked beautiful.

“Oh, fine, I guess,” she answered. Her eyes were anxious, though, and she wrung her hands.

“What’s the matter? Your counts look better today, I think you’re going to go home before long,” I continued. I could hear some of our team members shifting behind me, eager to move on to some of our sicker patients.

She hesitated, perhaps considering the gravity of the information she was about to impart: “I don’t want to die in the hospital.”

I met her eyes, and smiled a bit. “You’ve done great throughout your chemotherapy course, you’re on minimal medications, and your bone marrow is recovering. We aren’t at all nervous about you,” I said. “Why are you worried?”

She exhaled, though I couldn’t tell if she did so because she was relieved to hear about her good health, or frustrated that she had to repeat herself. “I’ve seen family members die in the hospital and I don’t want that to happen to me,” she said. “Promise me I won’t die here.”

“But you’re doing so well, your dying is the farthest thing from our minds.” I tried to reassure her.

“Promise me,” she repeated, her eyes now steely as she leaned forward, waiting for my response.

I hesitated, wanting to set her mind at ease but also trying to be careful not to make absolute guarantees. “I promise I will let you know the moment we’re concerned about you.”

She continued to stare at me, making clear that what I had said wasn’t enough. This time I exhaled before continuing. “I promise we won’t let you die in the hospital.”

She nodded, sank back into her pillow, and thanked us for seeing her.

Our conversation nagged at me.

Over the next couple of days, each time we walked into her room, we reaffirmed how well she was doing, but she would end the interaction by reminding me of my promise.

Early the following morning, I was paged with the news that, out of the blue, her blood pressure had plummeted, she had become confused, and she had spiked a fever. She was quickly transferred to the intensive care unit.

I went to see her, along with the entire rest of our team, no longer feeling much pride. She looked awful. By that point, a breathing tube had been placed and she was on a respirator. Her body had already started to swell, from the fluids that were being rapidly infused into her veins to keep her blood pressure up, and she was on two medications — pressors — to raise her blood pressure even further. I had checked her labs, which indicated that her kidneys were starting to fail, and that a bacterium had been identified in her bloodstream – the cause of this maelstrom of ensuing sickness.

Her husband stood by her bed. I went over to him and held on to the sleeve of his jacket, as if steadying myself. As many years as I have cared for people with leukemia, I still get thrown by how quickly they can get so terribly sick as a consequence of having a broken immune system.

“I’m so sorry all of this happened. It looks like she got a bad infection and it took over rapidly,” I said.

He nodded. “The doctors here in intensive care say she’s pretty sick and may not make it.”

“She’s sick,” I acknowledged. “And I’m worried about her.”

We stood silently next to each other, watching the respirator breathe for her, her chest rising and falling mechanically, during what would turn out to be her last hours on earth.

I continued. “I feel bad that I promised her that she wouldn’t die in the hospital. It’s almost as if she realized before we did what was brewing, what was about to happen.”

His face was kind when he looked at me. “You couldn’t have known. Even if she did.”

Perhaps. But even when the compassionate part of me aches to alleviate my patients’ fears, I should know better than to make promises I can’t keep.