From the moment we take our first breath, we all strive to find the optimum way of surviving the challenges life throws at us. From the moment we realize our mortality, we all strive to avoid a difficult ending and wholeheartedly hope for a peaceful final breath.

Certain events in our lives often help reveal destiny’s plans for us, giving us some precious time to prepare for the inevitable. However, only a limited few know the exact point in time of their “flight”. I have always wondered what my reaction would be if someone told me that my time was up. What would it feel like if I knew that my life was to be terminated? Would I know the exact mode and time of my demise? And would I still have time to say goodbye? MC had all these questions answered within 24 hours.

It was a sunny Sunday morning and MC was not in the mood to go to church. She wanted to have a quiet time in and enjoy her gardening. She was 83 years old and did not have any medical problems. She prepared some toast and opened the kitchen cupboard to get her teacup out. As she reached up, she suddenly felt the most severe pain at the back of her throat. “It was as if I was shot in the mouth”, she described. The pain slowly got better but then, the most unpleasant headache started to set in. She came to hospital “to have things checked out”. Her pulse was racing and her blood pressure was different between her left and right arm. She had developed some uncomfortable chest pain and became more nauseated since her arrival at the hospital. Her chest X-ray raised concerns about her aorta. She had a CT scan of her heart and blood vessels, which confirmed my suspicions. MC had aortic dissection.

The aorta is the body’s most important blood vessel and carries oxygenated blood from the heart to all of our internal organs. Like all arteries, the aorta is formed by three layers, including a more muscular lining that helps to propagate the blood along. These layers are made of collagen fibres that are essentially the body’s glue, giving structure and support to almost everything. Veins, on the other hand, are much thinner and only have one layer, which means they are less resilient and more prone to ballooning and to generally becoming more ineffective e.g. varicose veins. Veins lack the muscular layer and, for this reason, they do not have a pulse.

Aortic dissection is a condition where the lining of the aorta tears away, and blood begins to flow in between the vessel’s layers. As a result, a second channel forms in the wall of the aorta. This impairs the blood supply to the organs and increases the chances of the blood vessel rupturing altogether. There are many causes of dissection, such as high blood pressure, old age, hereditary conditions leading to defective collagen, like Marfan’s disease and Ehlers Danlos syndrome.
Strict control of the blood pressure and a highly invasive surgery are the only ways of treating the condition. During surgery, the patient’s chest needs to be opened up (thoracotomy). The heart is attached onto a bypass machine and the blood is routed around the lungs and heart with the help of an external device. This allows the blood to cool down, which means that the body’s oxygen requirements will also decrease. A solution is then given to stop/slow down the heart (cardioplegic solution). This allows the surgeons to identify the location and extend of the dissection. The dissected wall of the aorta is sutured together and a reinforcement graft can also be implanted for extra support.

MC was a trained nurse who worked for many years on a medical ward. She understood very well what the implications of her diagnosis and the risks of a potential operation were. I spent a lot of time describing to her and her family what her CT scan showed and what needed to be done. I had also arranged for her to be urgently worked up for emergency surgery under the cardiothoracic surgeons. MC smiled all the way through the consultation. She then told everyone what she was thinking. And it was not what everyone wanted to hear.

“I will finally see Tony again… my husband. Tony shall be waiting for me”, she told us with excitement. She went on to share that she had been feeling very lonely over the last 12 years since his death. She had tried to stay brave and motivated for the sake of her children and grandchildren. But for more than a decade, MC was hoping for “a sign from God” that she was to be reunited with the most important person in her life.

She politely declined surgery and told us that she was ready to go. Looking at me with her sparkly, cheerful eyes, with her smile still drawn confidently on her face, her words were assertive and clear. She felt like the luckiest person on earth because she got to know exactly how much time she had left. She was grateful she didn’t suffer from a chronic illness and was pleased she wasn’t dying from cancer. She felt fortunate she had time to call all her children in hospital and say her final goodbyes whilst she was still lucid and compos mentis. Her wish to see Tony had at last been granted and she had a few hours left to arrange her dignified exodus. She gave the key to her house to her eldest daughter. There was time to share her last stories with her family; time to kiss everyone goodbye; time to tell them how much they all meant to her. She had a light dinner and said her prayers. She lay down at 9pm and closed her eyes, knowing this would be the last time she went to bed.

She woke up the following morning in Tony’s arms. For MC, this was the most comforting of places and the most fortunate of endings. She looked down onto her hospital bed, at the old woman she could no longer recognize. She watched her family cry in unison next to her soulless body. She heard her grandson whisper “I love you Nana”, and tried for one last time to console them. And as the minutes went by, and as her presence became more distant, her memory was growing even fonder. It was this strong memory that taught her doctor one of the most fundamental lessons he could learn in medicine and life. The drive with which doctors strive to help and treat people is so powerful and instinctive, yet it is sometimes met by an even stronger force. The force that reminds us that at times “(with)drawing the line” confers the strongest comfort to a tired body and the most sincere and honest help to a bleeding soul.