When the numbers don't add up...

Mr Adams is a lovely old man. I was speaking to him one day and he said, “you look tired, do you want a sweet?” and offered me one of the Werther’s Originals from the packet on his bedside table. I thought this was so sweet and I gratefully accepted and said thank you. This was a week ago, and since then every day, after I see him on the ward round, he offers me one of his Werther’s Originals. It’s our “thing.”

Mr Adams’ liver isn’t working.

When patients have liver failure, the majority of what we do for them as doctors is dependent on what their blood test results. So, at 09:40 every morning, Mr Adams has his blood taken by the phlebotomists. The sample is sent to the pathology laboratory where it is tested and just after lunchtime, the results are put up on the hospital’s intranet as a collection of numbers. Back on the ward, I use the intranet to access his results so I can alter his medications/drips as necessary.

Mr Adams’ blood results were holding for a while, but on Tuesday they were very worrying. They showed that his kidneys had stopped working meaning he had what we medics call “hepato-renal failure.” This is very, very bad news indeed.

My consultant, Dr Fletcher, spoke to Mr Adams and explained, as sensitively as possible, what was happening. He told him that he had only a 1 in 20 chance surviving and that while we’ll give him all the right treatment so he had the best possible chance, prognosis was bleak and it would probably be a good idea to put his affairs in order if he hadn’t done so already.

Mr Adams was as stoical as ever and told us that his affairs had been put in order a long time ago and that he’d do his best to fight his illness. “I’ll tell you what’s funny doctor,” he said. “I feel better now than I’ve done in weeks.”

Mr Adams told me that he wanted to live to see his grand-daughters 5th birthday next month. Over the next couple of days, his kidneys improved and his numbers got better and I started to hope. I started to hope that we’d made a mis-diagnosis and this wasn’t “proper” hepato-renal failure. I started to hope that the numbers would continue to get better and that Mr Adams would improve. I started to hope that Mr Adams would be in the lucky 5%. I started to hope that Mr Adams would be able to see the smile on his grand-daughter’s face as she blew out the five candles on her birthday cake.

I was wrong. I got into work yesterday morning and Sue, one of the staff nurses, asked me if I could come and see him.

Mr Adams was taken a major turn for the worse. He was gasping and every time he took a breath you could hear this horrible gurgling sound from his lungs. Doctors and nurses call this the “death rattle” and it really is a sign that there’s no way back. Sitting around his bed were five members of his family, whom the nurses had called in the early hours of the morning.

I asked them to please give me a moment with Mr Adams and then did a quick assessment to try and see what his level of consciousness was. I then stopped all the medications on his drug chart and prescribed him only morphine (for pain), a sedative and a drug to dry up the secretions that were dripping down the side of his mouth.

I went into the quiet room with his family members – his wife of 43 years, his two daughters and their partners – and I explained to them what they could already see with their own eyes. Mr Adams is dying.

His wife started crying, then one after the other his daughters started crying too. I really liked Mr Adams and I felt myself welling up as well. But I had to be professional; it’s not my place to join their grief. When the asked me how long he had left, I had to take some deep breaths to keep my voice even. I said that, while it’s impossible to give an exact time frame, I thought it would be a matter of hours rather than days.

I was right. Four and a half hours later, Mr Adams took his last breath and died. After the family members left, I went into his room to certify him dead. As I was leaving Mr Adams’ room for the last time, I noticed a half-finished pack of Werther’s Originals still on his bedside table.

Rest in Peace, Mr Adams.