The Long Goodbye
Authors: Sherry A. Guardiano
Journal: Annals of Internal Medicine (2009)

On Being a Doctor7 April 2009The Long GoodbyeFREESherry A. Guardiano, DOSherry A. Guardiano, DOFrom Cheshire Medical Center, Dartmouth Hitchcock Clinic, Keene, NH 03431.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-150-7-200904070-00013 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail I listen for breathing. I feel for movement. A slow, low hush comes from within—then no more. I had done this same exercise numerous times over the past 4 months since starting my internal medicine residency, but this time it was different.I looked up at the tired, scared man staring intently at me and said, “She's left us.” The pretty young woman at his side calmly states, “She's in a better place now, Daddy.” They both break into tears and the sense of loss in the room is palpable. This was news I had delivered before but nothing prepared me to tell it to my dad and my sister.I gently close her mouth. Her face is so pale—so different from the pictures adorning the walls and her hospital bed. Angels hang everywhere. The cross prominently overseeing all. So much love ….I compose myself and calmly walk to the phone. So many people to call …. Methodically, the numbers are dialed, the news delivered, and the anticipated arrangements discussed.I thought I had said “goodbye” to her long ago. My mother's unremitting headaches and diplopia and history of breast cancer prompted my phone call as a fourth-year medical student to her doctor to order computed tomography. “I really don't think this is viral—she has double vision.” My husband, and fellow medical student, and I understood the course ahead when we saw the computed tomogram studded with masses in her brain. “How is she even speaking?” I asked her radiation oncologist.We heeded the warning to move up the date of our wedding. She made it. On the eve of our original date, she was admitted to the hospital for deep venous thrombosis. She saw my sister graduate from college and get engaged all on the same day. She made it to our medical school graduation despite the new horrific back pain. I made the call to her oncology nurse 2 days after graduation, “She needs a bone scan.”I started my internship with great reservation, but she would not let me delay my training. My sister had taken leave from her job so that she could help care for Mom. The guilt I had for not doing the same was crippling at times, but it was not what she had wanted.One postcall morning I received a call. “Sher, you haven't gotten the clothes ready.”“What do you mean, Mom?”“I see her. That little blonde ‘pill’ keeps running around my bed.” Little did she know, or maybe she did, that 6 and 9 years later I would have 2 beautiful little blond “pills.” She would dream vividly, and I believe she lived 30 years in those last few weeks.My mom was meant to be a grandmother like no one else I know. When I was a child, she would talk about how she could not wait to be a “grandma.” When we played in our Barbie doll house, she was always the grandma. She lived for my sister and me. She worked for us. She never missed a band concert, play, ball game, or ski meet. She encouraged us never to quit even when we were not successful. She would say, “Sometimes it's not the outcome that is important.”She had not wanted me to become a doctor. She worried about what kind of life I would have. Would I find love? Would I have time for kids? Would I be happy? She stopped worrying after she met Rob. She knew that together, he and I could accomplish anything.Flying home to Maine on postcall days only to return right before my next shift was taxing but necessary. My dad and sister were exhausted caring for her and trying to understand what was happening. We were inundated with calls from worried family. During one call, I was asked, “What do the doctors say?” I felt like screaming, “I'l tell you what this doctor says. She's dying. She is not going to get better no matter what I do or anyone else!”“Be prepared to come at any time,” was my only response.On one trip home, she began having seizures. I called her doctor, and we picked up the carbamazepine. I didn't take her to chemotherapy the following day. “What are you doing? She needs that to get better!” my father huffed. “No, Dad. It's done. Hospice is coming tomorrow,” I said. He didn't talk to me for 2 days. I know he felt that I had taken his hope away, but my mother had made it clear she did not want to go to the hospital again. My dad did not comprehend the odds the oncologist had given him when he said, “She might have a 10% chance of surviving another few months with another round of chemotherapy.” All my dad heard was, “She has a chance.” For 28 years, every kiss had been followed by “I love you.” How could that end?One week later, I was giving her lorazepam every 2 hours to prevent status epilepticus. She was no longer with us mentally, and she could no longer swallow the carbamazepine. Her morphine dose continually needed adjustment because every time we moved her, she winced in pain. We swabbed her dry mouth and lips constantly, hoping to keep her comfortable. It was just a matter of time. We lovingly cared for her and each other in shifts with the gracious help of our amazing hospice nurses.My sister is the spitting image of my mom in both looks and personality—beautiful, warm, and caring. My dad and I are more alike, but before all of this, we were not very close. We were as stoic as Mom and my sister were emotionally transparent and as quiet as they were outgoing. None of us ever asked, “Why?” We prayed. We cried. We loved. We changed.The mottling had begun on her knees and buttocks, and I explained to my dad and sister that the end was nearing. We were all curled up on my parents' bed that Sunday night watching Mom's favorite show, “Touched by an Angel,” as she lay in the hospital bed beside us. All day the death rattle rang, and I think I had actually drifted off to sleep when I suddenly realized I no longer heard it. I got up, took my stethoscope, and listened—it had been the longest goodbye, and I am still saying it.Sherry A. Guardiano, DOCheshire Medical Center, Dartmouth Hitchcock ClinicKeene, NH 03431 Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From Cheshire Medical Center, Dartmouth Hitchcock Clinic, Keene, NH 03431.Disclaimer: The opinions and assertions contained herein are those of the author and are not to be construed as official or as reflecting the views of the Department of Defense, the Department of the Navy, or the naval services at large.Corresponding Author: Sherry A. Guardiano, DO, Cheshire Medical Center, Dartmouth Hitchcock Clinic, 580 Court Street, Keene, NH 03431. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 7 April 2009Volume 150, Issue 7Page: 499-500KeywordsChemotherapyMorphineMouthNursesResidencyRunningSleepSports and exercise medicineStatus epilepticusVision ePublished: 7 April 2009 Issue Published: 7 April 2009 PDF downloadLoading ...