Eighty two year old Bernard and his wife Cheryl came in together at the request of
the Cardiologist. The Heart Failure Clinic he attended noted a slow rise and fall
in creatinine as he navigated the year and seasons. Every undulation of his
creatinine incurred need to increase and decrease diuretics.
“You have Cardiorenal Syndrome,” I declared taking my stethoscope of his chest.
“I who?” he teased.
Homework was assigned: Daily weights the same time of day the same way using the
same scale at home. Gifts where given: A log sheet and a free kitten calendar.
Medicines were prescribed with instructions detailing the first three arms of a
decision tree. The follow up appointment was made but the air was thick with
Next we met a week later he was in acute renal failure. He got a little confused
about the if and then I had laid out. Adjustments to medications were made then new
decision trees planted.
Next we met a week later he was decompensating and wheezing. His feet puffy in
“Not my best look,” he said.
Once again adjustments to the medications were made and the old decision tree
uprooted and a new one planted with shade and enough fertilizer and a follow up in 3
Three days later they arrived and he was looking well. A few strokes of a pen to
solidify a plan and we set a course on smooth sailings.
“I owned a funeral home before. I thought I would have to pick a casket,” he joked.
“Not today!” I prodded him back.
“I’m never doing dialysis,” he declared.
“I know. We will not need that now anyway,” I said happily.
His wife smiled and patted his thigh a “good job honey”.
We carried on for two years. I know. I have the kitten calendars to reference.
One day he came in urgently. He was completely off. A trip to higher altitude had
thrown him in a tizzy. His weight was spiking and climbing. He felt exhausted.
“How exhausted?” I asked.
“Well I swim 40 laps usually but lately I can only do 20,” he said.
My mouth gaped open. I was getting winded walking from my car to the office. I felt
exhausted listen to the image of him doing pool laps.
“I think that’s certainly a change but come on sir. 20 pool laps? You make me feel
like a slug,” I teased.
We tried again to rebalance his metrics. Logs, weights, tweaks, calendars, follow
ups, rinse and repeat.
Then one day he was better.
“What changed?” I asked because something changed.
“I fast every 3rd day,” he said.
As a part of his fluid restrictions he would fast with no food or fluids every 3rd
day. This kept the balance for months. I was astounded. Of course recommending a
fast to a heart failure patient seemed never to be an option!
“You certainly showed me a way to handle things,” I commended him.
He beamed. His wife patted her husband’s thigh again.
Months later his creatinine soared and he could not rectify. The edge of the canyon
was in sight. Dialysis was here to pick him up or drive on.
“Sir, do you want to jump or do you want to rest here on the edge of the chasm?” I
What will it be like? How will I feel? Will it hurt? What are my chances it will be
ok? For how long? How will I get there? Is this going to be hard on my wife? How
often? How long? Is this forever? How do they do it? What can I do still after? How
Sitting in a chair while your blood circulates mysteriously outside your body in a
room with others doing the same nonchalantly conjures the same dread and “how long?”
is the question that breaks the soul. To sit for 3-4 hrs three times a week in
captivity made mince meat of brave.
The questions consumed the air in the room. I did my best to answer and he did his
best to understand. I was just talking after the third question because I could see
he had already glossed over enough to not really being processing. He kept asking
questions out of a need.
I know that need. I know that reaction. It is a need to know but an unquenchable
thirsty. Questions that don’t have answers feel like sliding backwards on a sandy
“Sir, we are at a chasm. I have taken you to the edge but this is as far as I can go
before you must jump and meet me over the other side or just make camp,” I said.
He and his wife left. They would think about it tonight. Tomorrow was Friday.
Fridays are challenging days to navigate. There is no work day on the other side to
allow for preparations. I would do my best with what time I had to carve out
Friday came. They decided to jump.
I arranged a litany of destinations actions appointments to get everything sorted.
By evening he had a dialysis catheter and a spot was pending for him the following
Wednesday once the hepatitis panel returned.
The weekend loomed over us. He had to camp for the weekend then two more days of the
week. If needed, he was instructed to go to the hospital.
Wednesday came. He didn’t show up.
I got the call and the red swirling light blared signifying failure failure failure
in translation. He was MIA.
I called his home. Cheryl answered and said he had decided to camp and not jump. We
talked and I did not press but now I would need them to bare with me as I arranged
the dialysis line to be removed.
That evening as a very late add on after much pleading and begging the line was
The same people I begged to place it so quickly on Friday quickly met him to remove
it as well. They were silent as they worked on him. I got a text late in the day.
“It’s done.” I imagine they knew the reality of why they took it out because his
wife says they were so gentle.
He went home and I called him. Told him I was sorry to drag him up and down the
canyon to no avail.
“It’s ok. I just figured I had had enough,” he reasoned. He asked me how long before
he passed. I explained again we were at a chasm. It depended on what he ate and
drank and if he had any pain or anxiety that required sedatives. What he chose to do
on any day that might demand of his body something it couldn’t give would factor.
“So I’ll live longer if I fast?”he joked. “You have lived well being creative,” I
replied. He said he understood and then we said good bye. I almost said, “love you,”
before hanging up as if he was my family.
Two weeks later I got a call from Cheryl. She was driving around she said to all the
funeral homes her husband felt were nice having himself “set a standard”. He son
drove while she asked me again what to expect as he was now mostly in bed not awake
and not eating much.
Another chasm opened up and there were no concrete details I could give. I could
only say it was short. Their planning was timely. The moment of closure was upon us.
That night he died camping on the edge of life with heart and kidney failure. We
never made the leap across the chasm but merely observed it over in the distance and
chose to camp instead on the familiar side of living. The camp site had been
comfortable and amongst friends. The questions of what if and what then long
reconciled to insignificance.
I tell my patients I will take you as far as we can go. If you jump I will catch you
on the other side. If you choose not to jump the chasm I will remain camping with
you till the hard days grow into the quiet nights.
We are guides, chasm jumpers, and campers.