Aneurysm
Deborah L Schultz MD
Choose your prayers carefully for they may be answered.
One early October afternoon my then 68 year old hypertensive, hyperlipidemic mother called my sister with a “quick question”. She had been experiencing a tearing chest pain that “started in the front and landed between my shoulder blades and I can hardly breathe.” What should she do? My sister told her to hang up and call 911. My mother’s response? “Don’t you dare do that; I’ll just call your father.”
My sister left her medical assistant job and drove the twenty-odd minutes to our parent’s home. My dad was there; my mother had just gotten out of the shower looking grey and ashen. Still, no ambulance could be called: “I’m breathing fine now.” My father drove her to the ER, my sister closely following. Diagnosis as quick as the plain chest x-ray: much too wide a mediastinum.
They spent the next hour arguing with my mother. The helicopter was en route; she needed transfer to a tertiary medical center for treatment. She had never flown before and was more afraid of flying than of death. My older sister arrived, the bossy one, and with the promise of versed oblivion she agreed. I arrived three hours later to find her pain-free, hemodynamically stable and annoyed. Very annoyed.
Her older sister had died several months previously in that very same ICU and she wanted none of it
CT scan confirmed 5cm thoracic aneurysm with fresh clot. Pulmonary function tests surprised everyone—normal function despite a greater than 100pack year history.
Recommendation: surgical repair. Patient response: “not in this lifetime.” The cardio-thoracic surgeon on call that weekend was a “world renowned” no – nonsense German. He laid it on the line, never minimizing, never carefully couching his words. She refused again. And again. And again. His parting words to her:
“never smoke again, one cigarette will kill you” fired off as he quickly left her bedside, never once looking back. I spoke with the cardio-thoracic surgeon at my hospital and he agreed to see her. She was now more than annoyed, she was quite angry. “Don’t you try to run my life.” It turns out the city of proposed surgery had nothing at all to do with it.
She returned home one week later and for the next 44 months lived her life as she chose. Remarkably, she was able to quit a 3/pk day habit cold-turkey. Predictably she lied about the results of follow-up CT scans: “it’s still the same.” Sadly, after a brief “honeymoon” she fought with son and daughter—not speaking to him for 3 years, to her for 2 months.

Forty months after her initial diagnosis, she became extremely dyspneic walking to the kitchen. When asked how long that had been going on and she answered “a couple of weeks—what do you think it is?” My reply: you really need to see your doctor. She did, but not for 6 weeks. Her choice, not a scheduling issue.
Results: “the same” thoracic aneurysm now measured 9 x 12 cm occupying most of her right chest. O2 sats on room air in the low 80s. She accepted home oxygen, nothing else.
And we began the conscious wait knowing that something as slight as a cough; a hard stop with seatbelt across her chest; could burst the balloon that stretched from the aortic root to the renal artery take-off. I prayed, not believing for an instant that my father understood just how tenuous her situation was nor what to expect. All he knew was that it was “bad” and that she wouldn’t discuss it other than to say she was not –ever—going to have surgery. Case closed. I prayed that it would be quick, that she would not suffer, and that they would not be alone. I never dreamed that
God would send me.
Wednesday, October 6 th , was my father’s 73 rd birthday. That evening my mother became ill, vomiting multiple times. She stayed in bed the next two days but refused to see the doctor and, by Friday evening, was feeling well enough to send my father out for a fish lunch which she ate heartedly.
Saturday night, 11 PM she became extremely short of breath and began experiencing chest pain. She asked my dad to sit with her and hold her hand and only after the pain progressed did she allow him to call an ambulance—with strict instructions that they would come non-emergency. 5Am Sunday morning: a 45 minutes journey from the 2 nd floor bedroom to the living room. The paramedics were there within 5 minutes; hooked her to the monitor; started IV fluids and by the time they were up the hill and one block away sirens blared.
In the ER—Bi-PAP brought Oxygen saturation back to 90%; chest x-ray with the right hemithorax half-filled with fluid. Diagnosis: pneumonia—to the ICU awaiting surgeon/chest tube placement. Once settled, my dad went home to let the dog out and to call me.
9 AM Sunday morning: my father’s voice, tired but not frantic. “Your mom’s in the
ICU with pneumonia and fluid in her lungs. They’re putting a tube in now to to drain it.” Too late to stop it; to prevent the drainage of the fluid that I knew must be acting to tamponade her aneurysm. I knew then and, an hour away, wondered if we would make it in time. I asked if he had called anyone else. “No, and don’t call your sister”
I didn’t but called my “allowed” brother and he was on his way.
The 70 odd mile drive seemed to take forever.

Seeing left no doubt. So pale, tachypneic. Her chest and abdomen heaving as she struggled for each breath. Her words muffled by the Bi-Pap mask and the hiss of oxygen; her eyes pained but eerily calm. She, too, knew.
My brother caught my eyes and shook his head; my father said “they put the tube in and got blood”. My eyes fell, first to the pleura-vac--over a liter of bright red blood.
Next, the cardiac monitor: AFIB/A Flutter with pressures 80-90 systolic.
Confirmation. She was alert, wanted us to go home: “You have things you need to do.” I told her I needed to stay and asked if she was in pain—yes, a 5 or 6 out of 10.
Being the good doctor/daughter I asked the nurse for analgesia but was told they were hesitant to give her any because of her hypotension but that the doctor had ordered a chest CT—to confirm what we already knew. They finally gave her morphine and her breathing eased a bit and the pain diminished to a 4. She told me that she would not make my daughter’s wedding; that I should tell my father that this was, indeed, “it”; that she loved him; that she was not afraid; and that—hell no—she did not want a priest. I did what she asked and while we were waiting, my father said he wished my brother would come and make peace with her. I agreed but also said that it was time for everyone to make peace. He struggled—not wanting to make my mother angry—but then agreed. I made the calls and they were both on their way.
She was back in minutes with undisputable confirmation.
The intensivist on call that weekend came in. He had no knowledge of my mother, who she was, her values, her wishes, and seemed appalled that her family doctor had not previously “done something.” He could not believe that she had chosen this path that led her, dying, to his ICU. He started at the foot of her bed in a strange dance that would ultimately take him face to face, eye to eye with her. All the time telling her that she needed to be flown to Milwaukee for surgery; that her aneurysm was leaking; that she would die if she stayed there...today..tomorrow…but she would die. She said no. And no again. And no a third time. My father, overwhelmed and already mourning begged her, for him, to please go. She was quiet a moment, looked at me and then turned to my father and said, “well let’s get this over with.” The doctor and my father thought she agreed to surgery; I knew she just wanted them out of her face.
He left to arrange his hard won transport; she immediately became more dyspneic, sat upright, looked at me, clutched her chest, and said: “It’s a 10.” I ran out, told the doctor “she’s crashing” and got my dad out as respiratory therapist and physician went through the motions of trying to save her.
Within minutes he came to the family room. At that point she was unresponsive but still alive. What did we want him to do—intubate, run more blood, fluids,transport her?? My father saddened, fearful, at the brink of loss, said he couldn’t choose, and for the first time that day, the intensivist acknowledged her right to choose: “What would she want?”

We all reflected on her very often verbalized wishes. She had been very clear that she felt the burdens of surgery outweighed any possible benefit. She had chosen her course years previously and had not vacillated. My dad said that he had always thought that she was just saying that; that she would change her mind at the end—if it came right down to it—but that he knew that that was just his hope. He asked the intensivist to keep her comfortable and to get a chaplain.
The end was peaceful after all. My mother’s life ebbed away slowly as we circled her bed holding hands and praying my father’s favorite psalm. She was not in pain nor alone and we were there to support our father with our presence and our love.
When we left, we thanked the nurses and the intensivist for everything that they had tried to do; he said, “ well she got her wish.” He didn’t understand at all.
My soul and heart remain full of the images of that day and closing my eyes I still see and feel all. I still cry when I pray but less these days. And I am very careful now in what I ask for.
Deborah L Schultz MD