Discharge day ============= * Stephen W. Hwang Ella was going home. She had been admitted to hospital a few days before I started my month as attending physician on the medical ward. The history in her chart was all too familiar: 89-year-old woman from nursing home; Alzheimer's disease; inadequate oral intake; admitted with dehydration, hypernatremia and acute renal failure. She had a shock of frizzly white hair and a face crisscrossed with myriad fine wrinkles. Her eyes betrayed her confusion. I quickly curtailed my efforts at conversation after receiving a few mumbled, barely comprehensible words in reply. Abnormalities found in her laboratory test results had responded rapidly to treatment, but each time we stopped giving her intravenous fluids, her serum creatinine level climbed slowly but inexorably above the normal range. Her dementia had progressed to the point that while eating she would often forget that there was food in her mouth. As a result, the staff were feeding her with erratic success. Ella was clearly incapable of making decisions about her care. When I suggested that we arrange a family conference, I was told that her common-law husband, Zoltan, was already a patient at our hospital. Zoltan and Ella had been together for 43 years, and they always said that it had been “love at first sight.” Ella was a supervisor at a hospital in Montreal, and Zoltan, who was 15 years younger than Ella, worked as a technician in the blood bank. After their retirements, they lived in a small apartment in Toronto until their numerous health problems and increasing disability forced them 3 years ago to move into a nursing home where they shared a room. Zoltan had sleep apnea and COPD. Half a year ago, he was sent to our hospital because of episodes of decreased level of consciousness, and shortly therafter he developed acute respiratory failure. He had been in the ICU ever since, ventilated through a tracheostomy. Every effort to wean him had failed. Alert, intellectually intact, and fully aware of his situation, he continued to affirm his desire for aggressive medical care. Meanwhile, Ella's level of functioning had deteriorated. The nurse practitioner caring for Zoltan in the ICU told me sadly, “She came to visit him once about 5 months ago. She didn't even recognize him.” A small group of staff from the medical ward trooped down to the ICU to meet with Zoltan. He was a large man with keen eyes and a broad face that was strikingly smooth and unlined. When we gathered around his bed and told him why we were there, his startled look made us realize, with sudden embarrassment, that no one had informed him that his wife had been in the hospital for the past week. After explaining Ella's situation to him, we raised the questions of whether Ella should have a feeding gastrostomy tube, and whether the nursing home should send her back to hospital if she became ill in the future. Zoltan listened attentively. Unable to speak because of his tracheostomy, he communicated by writing on a clipboard. He asked for Ella to visit him, which we quickly arranged for later that day. Alina, the intern looking after Ella, returned to the ICU a number of times to talk with Zoltan about Ella's care. Although Zoltan's first instinct was to do everything possible for Ella, he came to realize that Ella herself would not have wanted a feeding tube in this situation. Despite his conflicted feelings, Zoltan decided to honour what he thought would have been Ella's own wishes. But the question lingered of whether she should be brought back to the hospital if she got sick again. He could not make up his mind. Somewhat surprisingly, Ella began to eat more. With her condition improved, her discharge day had now arrived. I decided to stop by the ICU to find out Zoltan's decision regarding her care. I found him sleeping, despite the cacaphony of sounds that surrounded him: the relentless rhythmic swoosh of his ventilator, the chaotic alarms and beeping from monitors throughout the room and the hum of innumerable conversations. “Hi, Zoltan,” I said, waking him with a pat on his arm. “Do you remember me? I'm one of the doctors looking after your wife.” He nodded. “I wanted to talk to you about Ella. She's ready to go home today.” Zoltan's eyes widened slightly. He gestured with his right hand to mimic writing, and I quickly found the clipboard that was kept at his bedside. It held a piece of paper that was already covered with writing. ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/174/8/1138/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/174/8/1138/F1) Figure. Photo by: Fred Sebastian “Just a second,” I said, “I'm going to get a fresh piece of paper.” I stepped away holding the clipboard and glanced down at Zoltan's wobbly but legible script meandering across the page. It was as if I were listening to one side of the conversation that had taken place the day that Ella had come to visit him. Although robbed of his voice, Zoltan's words during and after that reunion were preserved on the slightly crumpled sheet of paper clinging to the clipboard: Sweet baby Look great I love you Dearest darling So nice to be together How are you I missed you the whole time I love you my sweet baby Sweetie eat and drink to live You are a darling Shall we dance Jesus be with you I love you Speak slowly Why you take her away She come back later Can you bring my wife ATIVAN Kleenex A boost up I paused for a moment and then returned to his bedside. “Would you like me to bring Ella to visit you before she goes home?” “Yes,” he wrote. “I just wanted to be clear about what you want us to do for Ella. I know you've decided that we should not put a feeding tube into her.” “Yes,” he wrote. “If she gets sick at the nursing home, do you want them to send her back to the hospital?” “Yes,” he wrote. I asked Violet, the nursing assistant looking after Ella, to get her ready to visit Zoltan. When I arrived in her sun-filled room, Ella was seated in a wheelchair. A twisted white bedsheet, loosely tied, encircled her waist and looped around the back of the wheelchair to prevent her from falling. Violet had changed Ella out of her standard-issue hospital gown and into a floor-length light-blue housedress with a ruffled frill. “Ella kept telling us that she'd brought a ‚beautiful blue dress' with her,” Violet told me. She turned to Ella with a grin. “So here you are, Ella, in your ‚beautiful blue dress,' all ready to go see your hubby!” I took Ella down to the ICU and rolled her to her husband's bedside. He was resting, his eyes closed. Ella's face brightened as I had never seen it before. “Zoltan,” she murmured. He opened his eyes and smiled at her. Ella leaned forward in her wheelchair, caressed his left hand gently, and kissed it softly time and time again.