Mrs. Myers (not her real name) was a 69-year-old woman with a long history of alcoholism that had ravaged her liver. She had developed a fallopian tube lesion, and through the urging of her son (and ostensibly the surgeon), had decided to have surgery to remove it, and, she hoped, lessen the abdominal discomfort and obtain a definitive pathologic diagnosis. Surgery went well, but the postoperative course was tumultuous, with sepsis and renal failure, requiring mechanical ventilation and dialysis. Fortunately, Mrs. Myers was eventually extubated, but she was agitated and begging to die. When her son arrived at bedside, she blamed him for everything—instilling a guilt that crushed his heart. His history was also not without sickness — a year earlier, he had undergone a liver transplant complicated by bleeding and three subsequent surgeries. But he recovered, and became his mother's caregiver as she fought the cirrhotic ruin of alcohol.

And now, he stood alone in her intensive care room as she pleaded to die, to leave her misery behind. I asked if either of them had a religious faith and if they would like to speak with a chaplain, but he said that neither of them were particularly religious, and declined.

“Let me die, when am I gonna die? You did this to me!”

Her voice pierced our conversation — he walked to the head of the bed and tried to ease her anguish, but to no avail — and her moaning and pleading continued. The intensive care team had spoken with Mrs. Myers previously, deemed her to have decision-making capacity, and with agreement from her son, had consulted me with a goal of instituting comfort care and allowing her to die a natural death. I explained to Mrs. Myers and her son what would be done to ease her distress, that a continuous morphine infusion would be started to help with her pain and breathing, and that lorazepam would also be available should she feel anxious. Her son paced the room with tears in his eyes — I offered support and solace, but his mother's words hung heavy with blame.

As the morphine infused and Mrs. Myers relaxed and drifted to the twilight between life and death, her son approached me. “She blames me for this doctor, she says I caused all of this. Did I doctor? Please tell me, did I?” I stumbled mentally.

I looked into his troubled eyes, then told him I would review her chart and give him my thoughts on the need for surgery. He was clearly suffering from his mother's words, and after facing death himself a year ago with a liver that continuously teetered on rejection, I felt obligated to provide him with my opinion — in my mind, it was the least I could do. When I viewed the old records, pathology demonstrated a benign fallopian tube cyst, but I was unable to ascertain the urgency or necessity of surgery, if it was thought to be malignant prior to surgery, or the degree of discomfort it caused Mrs. Myers — clearly, I would have had to have been there to understand the dynamics involved in the decision to proceed with surgery. But I wondered what would have happened had there been no surgery, had she continued on with her life with a bottle in her hand. I pondered all of the scenarios, including the need for emergent surgery should the cyst have ruptured and Mrs. Myers presented to the emergency room with an “acute abdomen,” or if the pathology had revealed a cancerous growth that had metastasized with watchful waiting. But with her alcohol abuse and cirrhotic liver, would it have even made a difference? What would I, or rather what should I, tell her son? What would help with his grief and bereavement and lead to emotional healing? What would be the right thing to do? Difficult questions certainly, yet questions that begged for caring answers.

I felt like I had plunged head first into an ethical quagmire with no hope of escape. Mrs. Myers was going to die, and with her comfort now assured, I felt obligated to provide comfort for her son. But what should I say? If I felt the surgery had not been necessary, Mrs. Myers's son's grief and guilt would be compounded immeasurably, yet if I told him it had been necessary, his grief would be lessened but my moral integrity as a physician would be violated — or so it would seem. If I told him that I couldn't determine whether surgery had been necessary, that I could not provide him with a definitive yes or no answer, I would be honest and truthful but his guilt would undoubtedly remain deeply rooted and contribute to his continued grief and emotional torment. He needed to know that he did not contribute to his mother's death — nothing more, nothing less. The moral and ethical controversy was palpable as I silently argued my options — I wondered if lying and deception were ever permissible in a physician-dominated relationship. Religious moralists would certainly answer with a resounding no, as would many physicians, but in this situation, would God touch this suffering son and allow a sense of relief by pardoning the utterance of a few healing, yet potentially untruthful, words?

I stood and walked to Mrs. Myers's room and peered inside — her son was bedside, caressing her arm as she moaned and pleaded to die. I asked him to step outside where we could talk. I pulled up two chairs, sat down, and leaned forward and recounted what I had read in her chart — that I could not discern the extent of her pain or any definitive presurgical thoughts regarding the necessity of the operation or the possibility of malignancy, only that the cyst was benign. His voice cracked as he again asked “Did I do this doctor? Please tell me, did I do this?” I silently thought of the suffering that they both had endured — it seemed as if everything the rolling stone had gathered before it surfaced in the lonely environment of the intensive care unit was plainly evident: love, hate, and all things in between.

His voice softened, and again he asked “Did I do this?”

Time seemed still as we sat there, the seconds feeling like hours. I paused, took a deep breath, and then spoke the words he wanted to hear: “You did the right thing, you did the right thing.” The furrows eased, and he cried.