I dialed 9-1-1 for the first time. It was 9:00 pm. My friend Griffin and I were stranded on a six-inch rock ledge above a granite wall on the face of Cannon Cliff in New Hampshire. That morning, we set out from the parking lot of the cliff and made our way to the foot of “Moby Grape,” an 800-foot climb up the middle of the cliff. We had made good time on the approach trail, but our efficiency quickly faded once we roped up and started up the granite. Though I have been climbing for 19 years, I often forget how scary the activity can be when deconditioned to the vertical exposure that comes with climbing a long route. What I had expected might have taken us 8 hours, took us 10. I was dehydrated, my lips and tongue glued to my teeth with a white ring of salt around my mouth, and by 8:00 pm, my hands and feet were shaking. I wasn’t thinking clearly. The last section of climbing seemed too dangerous to pursue. A slip, likely at that point, could have resulted in severe injury.

Instead of tempting fate, we tried to traverse around the side of the cliff, hoping to join the descent trail via a system of disconnected ledges. We constructed an anchor that enabled us to rappel under tension across the blank granite slabs to our right with some sense of security. I reached the end of the rope, standing on a humble (but less than vertical) six-inch ledge with no place to build another anchor. We could no longer safely continue at all. The shadow of the cliff face grew larger and larger along the valley floor below us. The sun was setting; pink, blue, and orange hues filled the valley floor. It was now time to call for help.

For four hours, Griffin and I waited on our six-inch perch for the rescue team to arrive. Black flies nibbled at our ankles, knuckles, and eyes; we talked about the best moments of our childhood and of high school, about the scariest moments of our lives thus far, love, and our families. With the sun fully set, a chill set in, and the Milky Way lit up the sky. By 12:30 am, headlamps appeared on the descent trail a few hundred meters to our left. Just over an hour later, Rusty, a local climbing guide, abseiled to us and secured us to his ropes. The three of us ascended his ropes to the top of Cannon Cliff and were grateful for the secure, level footing under our feet.

I started my intern year in Internal Medicine at Brown University in Providence, Rhode Island, one year later. While the structure of residency training made me feel supported as a new physician, I encountered a new degree of independence in my medical decision-making. Based on what ensued the year prior atop Cannon Mountain, I trusted that my gut would tell me when I needed to ask for help. I gradually gained comfort in making management decisions and leading family meetings.

This proved to be a valuable skill as I began my night shift rotation, which requires rapidly learning the clinical details of many sick patients over the course of an on-call shift. One such patient was initially admitted for a hip fracture but developed sepsis and briefly stayed in the intensive care unit (ICU). Although initially improved enough for intermediate level of care, his clinical condition deteriorated over a few hours. A nurse who had previously taken care of him in the ICU stated that he looked like he was “about to die” and called my senior resident and me down to evaluate him. He looked as described: mouth agape on a bilevel positive air pressure mask, hypotensive in atrial fibrillation, and cold to the touch.

We determined at 4:00 am that we needed to facilitate goals of care conversation with the family. By 5:00 am, all four of this 91-year-old’s family members had gathered around his bed, all of whom I had met or talked with over the phone the hour earlier. When I pulled up my chair to assess their understanding of his care and what his likely prognosis would be, it seemed like they had already known what was unfolding before any mention of comfort-focused measures. “He looks about as comfortable as I’ve seen him this stay,” his son said. “Let’s prioritize that.” At 5:20 am, his family decided to focus his care on comfort. I had just signed the order for a morphine drip when the patient’s nurse, the same nurse who knew him in the ICU and who had inherited his care in the step-down unit, let me know that he was bradycardic, with a heart of 20 beats per minute. By 5:45 am, his cardiac monitor showed asystole.

When I walked into his room, his family was still at the bedside with tears welling. The patient’s chest had ceased to rise and fall. His heart sounds were absent, his pupils unreactive; he did not withdraw to pain. Everyone in the room knew he would die, and now he had died, but none of us realized how quickly it would happen. I felt like I had been his doctor for months. I did not feel as I did on that ledge in New Hampshire, where Rusty came to my rescue. I felt ready and able to assist this man and his family in the direst moments of his life.

Back upstairs in the call room, my senior resident, the night attending physician, and I debriefed the events leading up to the patient’s death. The step-down unit was an eventful place that night. Some of our patients were hypotensive; some of our patients had chest X-rays with findings of ARDS. For those patients, I turned to my senior resident for help. For the patient who died, though, it seemed as if everyone in that room knew what was happening and that everyone who needed to be there had already arrived. “Sometimes, patients know when they should die,” my senior resident said. “Sometimes, they are just waiting for family.”

So just as Griffin and I waited, near death, for Rusty to rescue us and move us to a better place, my patient waited for his family to save him and take him to a better place.

Conflicts of Interest/Disclosures

The author has no conflicts of interest to disclose.

Corresponding author

William Doak, MD
Department of Internal Medicine
Warren Alpert Medical School of Brown University,
Providence, RI 02906
Email: William_doak@brown.edu