“There is nothing you can do to stop me.”
"I’m going to drink myself to death and there is nothing you can do to stop me.”
This was Gil’s second alcoholic hepatitis. He
and I both thought he was going to die 2 years earlier when he had been
hospitalized for aspiration pneumonia. He had been drinking heavily and
vomited when he passed out and then breathed it back in. This caused a
severe infection in his lungs and he was on a ventilator and intravenous
antibiotics for several weeks.
His mother signed commitment papers and Gil was sent to an inpatient program for 3 months. After he got out, he really did want to stay sober and was going to AA meetings and was staying clear of his old drinking friends. He was coming in for regular visits for awhile, but then he moved away from Seattle and I didn’t see him again.
When his mother died and he came back for her funeral, he stayed with his old girlfriend and they started drinking again. She finally noticed Gil getting bloated and yellow and brought him in to see me. His bilirubin level was very high and was the reason for his yellow skin and eyes. Platelets are made in the liver and help with blood clotting. The level should be over 150 and his were at 37. This put him at risk for not being able to form clots if he fell or started bleeding for any other reason. If they went below 20 he could start bleeding spontaneously.
He refused hospitalization and he refused to quit drinking. “With my mother gone, I don’t have any reason to live. I know what I’m doing.” There were no family members in the area to sign commitment papers and his 2 brothers and one sister had been through this several times before with him and wouldn’t even consider signing them again. His girlfriend stuck by him, but she didn’t have any legal rights to force him into treatment. He had been in treatment 7 times in the past and never really stayed sober for very long after getting out of any of them.
He went home and continued to drink. His girlfriend brought him in after he fell in the bathroom. He had hit his lip on the sink when he fell and had a cut on his lower lip that had been bleeding for the past 2 weeks. He was continually swallowing blood and this caused lots of nausea. He had to go in to the hospital for a transfusion as he dropped his blood count down and his platelets were now at 29.
Albumin is a protein made in the liver and it helps hold fluid in blood vessels. His was so low that fluid was leaking into the tissues of his legs and into his belly. His legs were tense, dark, shiny and thick from the fluid built up in them. His belly was getting bigger and pale blue veins radiated outward and looked like worms under the skin around his navel. He had spider angiomas all over his chest. These are red spots with blood vessels coming out from the center and are seen in liver failure. His bilirubin continued to rise.
He needed 3 transfusions to make his lip stop bleeding and he went back home. His girlfriend brought him in again when he started vomiting blood. Not much at first, but it was getting worse. He had another transfusion and a scope procedure to look into his stomach and it showed a small ulcer. This was cauterized to stop the bleeding, but the Gastroenterologist noted esophageal varices. These are large blood vessels that form in the esophagus when blood can’t flow through the liver. These are often fatal if they break open. This was explained to him, but all he wanted to do was to go back home.
I saw him again a few weeks later because the fluid in his belly was making it hard for him to breathe because he couldn’t expand his lungs. I could hear the fluid splashing as he walked and it actually made him sway as it splashed from one side to the other. He was short of breath and could only speak in 2-3 word sentences. The amount of fluid we have in our abdomen to lubricate our internal organs is normally less than a can of pop. The Radiologist drained 9 liters of fluid from Gil’s abdomen. This is 4 of those big 2 liter pop bottles. The fluid was back in a few weeks and he was short of breath again. This time he had 6 liters drained and there was a complication. The hole where the drainage needle was inserted wouldn’t clot and he developed a persistent leak of sticky yellow fluid. This soaked through all bandages and soaked his sheets and clothing. He felt cold all the time and was also soaking the blankets at home.
The fluid began to reaccumulate, but he didn’t want to have it drained as this caused him severe nausea. As the fluid built up, it spread into his scrotum and swelled it larger than a cantaloupe. The swelling made him unable to urinate and had to have a catheter passed through his penis and into his bladder. He had to walk slowly with his legs spread wide as his scrotum was painful and swollen. Soon he was unable to walk at all and had to be in a wheelchair.
We discussed a living will and he had no problems signing a form refusing resuscitation efforts, “If I go like this, I don’t want anyone bringing me back.”
He was intermittently delirious due to a climbing ammonia level. The treatment for this is a laxative and he started having continuous liquid stools. His belly was still leaking from the drainage site and his scrotum was getting larger and increasingly painful. Fluid was oozing from multiple open sores in his swollen legs.
He started vomiting blood again and was hospitalized. He refused to have another scope of his esophagus and refused to take any more of the laxative. He refused a drainage tube into his stomach through his nose and continued to vomit more and more blood.
His girlfriend and his brother were with him.
Just before he died he told his brother, “Dad drank himself to death at 40.
I always thought I would make it at least that far.”
Arne Vainio, M.D. is a Family Practice Physician at the Min-No-Aya-Win Human Services Clinic on the Fond du Lac Ojibwe Reservation in Northern Minnesota. He can be reached at firstname.lastname@example.org.