How Do I Know When to Say When?
What to listen for when your loved one is dying.
Filed under: Collapse of Care
Connected to: Rule #3: Collapse Always Falls on the Vulnerable First
Tags: end-of-life, emergency medicine, families, critical care, collapse, aging
This isn’t a story about death. It’s about how modern medicine fails to speak plainly—especially when the decisions are hardest. If you’re caring for an aging parent, partner, or loved one, this is the translation guide you were never given. These are the phrases families hear in ERs, ICUs, and late-night phone calls—phrases that signal when it might be time to stop, to honor someone’s wishes, and to let them go with dignity.
He was 93 years old. Advanced coronary and peripheral artery disease. Vascular dementia. Brought in by his daughter—kind, composed, and scared. She noticed a new left bundle branch block on his home ECG monitor. That alone makes this unusual. But she was right. His ECG from a week prior had been normal. Now it wasn’t.
Her father had been in pain. His abdomen hurt, and she was worried it might be something acute—a clot, a perforation, a missed catastrophe. But he wasn’t asking for anything. He could say his name and date of birth, but not the year. Couldn’t tell me where he was. That was his baseline.
He’d been evaluated before. He wasn’t a candidate for surgery. Or for cath lab intervention. Or anything invasive, really. His daughter had the paperwork. She had the medications. What she didn’t have was certainty. She needed someone to tell her that not doing more didn’t mean she was giving up. That letting go could be the right thing. That saying “I just want him to be comfortable” was enough.
So we talked. It was 11 p.m. on a Tuesday. The hospital was full. The resources were stretched. But for ten minutes, we stood together in the truth. That he was dying. That she didn’t need to save him. That her job now was to love him, to comfort him, to honor his wishes.
Before she left, she stopped and said: “I really want to thank you for the time you spent talking to me. It meant a lot.”
This is what collapse looks like: A daughter with morphine, a home ECG, and a dying father, trying to interpret the unspoken language of the end. And this is what I want others to have: A guide—not for what to do, but how to know when it’s time.
What You’ll Hear—And What It Really Means
“We’ve started vasopressors.”
Translation: Your loved one is in shock. Their blood pressure is dangerously low. Vasopressors are used to artificially raise it—temporarily.
Why it matters: In older adults, especially those with dementia or heart disease, this often signals the beginning of the end. The survival rate is low, and if they do survive, they may never return to their prior baseline.
Ask yourself: Would they want to be kept alive by IV medications, unable to speak or move, if this is where it’s heading?
“They’re not a candidate for surgery.”
Translation: The surgeons believe your loved one is too unstable or frail to survive the operation.
Why it matters: This isn’t about medical nihilism—it’s about reality. When surgery is ruled out, and nothing else will fix the problem, it often means the body has nothing left to give.
Ask yourself: If even the most aggressive options are off the table, is it time to ask what they would have wanted?
“They’ve been intubated and placed on a ventilator.”
Translation: They can no longer breathe on their own. A machine is doing the work.
Why it matters: Intubation is not recovery. It’s often a holding pattern. In the elderly or those with chronic illness, it frequently leads to a prolonged ICU stay, and death.
Ask yourself: Did they ever say, “I never want to be on a breathing machine”?
“We’re seeing multi-organ failure.”
Translation: Multiple systems are shutting down—kidneys, lungs, heart, liver. The body is turning off the lights.
Why it matters: This is not survivable in most cases. If they do survive, they will not be the same. Not even close.
Ask yourself: Is there a chance for recovery, or only survival in name only?
“Their code status is full, but we wanted to clarify…”
Translation: We will attempt CPR, electric shocks, and intubation if their heart stops. But we’re giving you a chance to reconsider.
Why it matters: This is often a warning shot. The team believes CPR will be futile or violent—breaking ribs, extending suffering, not saving life.
Ask yourself: Is this what they wanted? Or just what the form says?
“We’re prioritizing comfort now.”
Translation: The shift has begun. The team is focusing on pain, dignity, and peace.
Why it matters: This is the moment to stop fighting the inevitable and start protecting what’s left. You are not “giving up.” You are giving grace.
Ask yourself: What matters more: another 12 hours of suffering, or 2 minutes of peace?
Why This Matters
We are entering a demographic cliff. More people are living into their 80s and 90s—many with dementia, multiple chronic illnesses, and no clear advance planning.
But even when families do have advance directives, they’re often sidelined by guilt, confusion, or fear. Why? Because no one told them what to expect. No one translated the signals.
And the system? It doesn’t stop to explain.
Rule #3: Collapse Always Falls on the Vulnerable First
You will not be warned. You will be called at 2am and asked to make a life-or-death decision for someone you love based on five words you don’t understand. That’s not your fault. That’s the system.
One Final Reminder:
Saying when is not quitting.
It’s not betrayal.
It’s not abandonment.
It’s the most courageous act of love you can offer—
To say, “You can stop now. I’ve got the rest.”