Disclaimer: refer to chapter one

NOTE TO READERS: Okay, I apologize for not posting last weekend but things are very hectic on my end and I just couldn't do it, sorry! Thanks as always for the kind PM's and reviews, they are all appreciated. This chapter is around 9 pages long, so at least it's not super short. I still have some more chapters planned but the finish line is coming into sight. Happy Reading, I hope!

So Long, Good-Bye

Chapter Twelve: All Apologies

By Dawn Nyberg

"…I know you didn't bring me out here to drown, so why am I ten feet under and upside down, barely surviving has become my purpose cause I'm so used to living underneath the surface …" lyric excerpt by Lifehouse, Storm

Greene Memorial Hospital, Day Ten of IV Treatment, Sam's Room

"K, D'n," Sam forced out.

"Look Sammy, I know you want out of her man, I do, but the doc says you got to finish the IV antibiotics first, okay? Look the infection is clearing up but we gotta make sure and the doc says you need the full 14 days, okay?" Dean could see the disappointment in his little brother's eyes but at least his eyes were clear and not glassy with fever like they were for the first couple days he was in the ICU. Sam was in a regular room now but Dean still felt like he was on high alert waiting for the other shoe to drop but Sam was holding his own and doing better with the IV. Their father was still in town but he was stepping out for hours at a time now since Sam was out of the ICU. Dean could feel something was on the horizon and he forced himself not to feel the hope that was burning so badly to be released … hope that their father was going to fix this, and save Sam.

Later that Day

"Dean?" Dr. Finley spoke from the door threshold to Sam's room. His patient was clearly sleeping and he was glad the sleep appeared restful for the young man.

"Yeah, doc?" Dean stood up quickly keeping his voice quiet in order not to wake his sibling. The physician motioned for them to step out in the hallway. Dean felt his stomach clench in response. His eyes were intense when he prodded the doctor quickly. "What is it? Is it Sam? Is the infection worse? What?"

"Easy, Dean," the doctor tried to assure but Dean could see something in his eyes.

"But there's something, right?"

"I know this is a sensitive topic for Sam but we're at that point now …" Dean wasn't sure where this conversation was headed but he began to feel nauseous.

"What point? You said he's responding to the medicine," Dean's voice shook.

"His nutrition Dean, he really needs to consider the TPN if he still refuses the surgically placed feeding tube."

"Can't we supplement more through his NG tube?" Dean questioned.

"He needs more Dean and he's lost over fifteen pounds in the last month and half. He was already lean with a lot of muscle when he became ill but he's bedridden mostly except for when he's in his wheelchair. He's losing muscle mass and he had little fat to start with … he needs help Dean. The physical therapy is helping his muscles not completely atrophy, but he's edging into malnourished. You and the home health care staff have done an excellent job but the NG tube just isn't getting the job done." Dean rubbed a hand across his tired eyes and then ran it over his hair.

"I'll talk to him, okay?"

"I'd like an answer today," the doctor stated.

"What if he says no?"

"Then we'll do as much as we can with the NG tube and may initiate some home IV treatments to supplement his feedings that aren't a TPN. I don't think I need to say this Dean, but you need to hear it … the weaker his body becomes from lack of proper nutrition the more his immune system is going to break down …"

"You mean he might make himself open to other infections?"

"Yes, but unfortunately with his advance directive on file and a copy of his living will is on file as well with our hospital, if he declines, additional treatment cannot be reinforced. He made his wishes clear when he still possessed all of his faculties and could verbally communicate effectively."

"But, I have his healthcare power of attorney," Dean pushed. "If he needs something that is medically needed I can okay it, right?"

"Only if it is within the allowances of his directive, Dean. The hospital must honor the advanced directive. It's a legal document."

"I know, okay," Dean hissed. He was angry and scared, a bad combination for a Winchester, let alone a big brother in full protect mode. "Can I take a look at his directive again? I've read his Living Will but I admit his directive I've skimmed. I figured it didn't say any more than his Living will."

"Sure I have a copy attached to his medical file at the desk. There is also another copy on file in Hospital Legal Services Department. Are you looking for something?"

"Maybe, I just want to see what Sam put in there. I know there were some revisions after I witnessed and then he used a nurse during that one visit."

"Here," Dr. Finley handed the paperwork over. "There are pre-filled in options but Sam opted to fill in the area that allows for more specific items. Of course, they were formalized a little with the legal department during the revision Sam had wanted," Dean nodded and read over the special instructions/wishes section:

Should I develop a life threatening infection due to my condition that is not responding to treatment and there is no chance for a meaningful recovery (definition of meaningful: that I can return home to continue receiving home care); I wish to have pharmaceutical interventions ceased and nature allowed to take its natural course.

If I am placed on a ventilator and my condition is such that I will not be able to sustain my life without artificial respiration; I wish to have the ventilator support withdrawn.

Should my heart stop beating due to a complication that I could recover from I wish to have CPR and advanced life support, however, if it is due to the withdraw of treatment or the arrest is part of my disease process and there is no hope of meaningful recovery then let my life end naturally and do not attempt to prolong my death.

It is my desire to have my nutrition needs met by NG tube and/or mouth (if able to swallow safely). I do not want the surgical placement of a feeding tube at any time.

I desire IV hydration should it become necessary, so that I may be kept comfortable.

I request to have any pain and any anxiety controlled by any means deemed medically appropriate (i.e. IV medication, PCA pump, pain patches/solutions/injections).

Dean wanted to be sick but he took a deep breath and focused on the words, his little brother's wishes. He had to find a way around Sam if it came down to it. "Here," Dean pointed.

"What?"

"It says he doesn't want a surgical tube…"

"Yes, but what are you getting at?"

"He hasn't written down express wishes to refuse a TPN. He says nothing about IV nutrition."

"Dean, it's splitting hairs," the doctor hedged.

"Look, I'll talk to him, but he hasn't written it in his directive. If he had, I'd respect it. I wouldn't like, in fact I'd hate it, but I'd respect it, but he didn't write it down."

"But, he's said to the best of his verbal ability Dean that he won't approve the TPN."

"Then knock his ass out and hook him up, he'll never be the wiser … juice him up, and pull the IV before you let him wake up. Prescribe some IV's that can supplement the tube feedings he gets at home … there has to be something. I'm not losing him because he's not getting enough nutrition through his tube. I never agreed to let my brother essentially starve to death." Dr. Finley could see Dean's determination. He shook his head.

"It's not that simple and certainly it'd be unethical," he mumbled under his breath and rubbed his face in frustration. "I can't…"

"I said I'd talk to him, look if you won't do it, then isn't there something you can prescribe; send him home on an IV … anything to help?"

"There are some options, but…"

"But, the TPN is best…"

"Well, honestly, Yes and no," the doctor scrubbed a hand over his face once again."

"What'd you mean?" Dean's eyes were intense.

"Well, the TPN can be a lifesaver but it's a double-edged sword Dean. It's not easy on the organs that are involved in digestion like the liver, gall bladder; pancreas … sometimes the organ damage is severe enough to warrant transplantation. He'd have to have frequent blood tests to monitor his body's reaction to the TPN. Plus, it does leave his bloodstream open to potential infections although great care is taken to avoid that…"

Dean shook his head, "Okay, what else is there … Sam's not strong enough for that crap. Organ damage, please there has to be something."

"I'll talk with our clinical dietician and try to come up with some alternatives and nutritional formulas, okay? I'll go talk to her now and I'll see you both later." Dean nodded.

"Thanks, doc," he offered the physician a soft smile.

Four Hours Later, Sam's Room

"Sammy, I was talkin' to the doc earlier while you were sleeping," Dean started and watched Sam make an effort to look at him as his eyes fought to stay on his big brother for a few moments. "He says you're losin' to much weight kiddo and you can't afford it. He says your immune system is going to start suffering soon …"

Sam wasn't stupid he might be trapped in his body and stuck with a brain that he had to fight tooth and nail to get to do what he wanted but he knew where Dean was headed with this conversation. He shook his hand at his brother. "Nnnooo," he slurred. "Nnnoo, T … P … N…" he forced out to make himself understood. Dean sighed.

"Yeah, it turns out as good as the thing is it might not be that great for you Sammy. Look, I'm having the doc look into some other nutrition stuff for you … how about we avoid the TPN but would you be willing to try some IV's and maybe some additional tube feedings or something?" Dean was grasping straws and needed his brother to agree to something, anything to keep him here, alive. There was a long silence and Dean watched his brother's wheels turning in his head. "Sammy, I can't watch you starve to death, please Dad and me we can't …"

"I … V… oookay," Sam struggled. "Mmm…more fff…feedings, Okay," he garbled out. Dean smiled and reached over and let his palm flatten on his little brother's chest and patted it gently.

"Thanks Sammy," his voice was soft as he fought the emotion grabbing his throat muscles. He patted once more and made light of the situation, "we'll put some meat back on that bean pole body of yours in no time." Sam offered his brother a small lop-sided grin and met eyes with him for a few seconds. That brief moment meant everything to Dean.

Two Weeks Later, Bobby's House

Sam's room in the library looked more like a hospital room. There was an IV pole that supplemented certain vitamins for Sam and Dr. Finley had instituted a modified tube feeding called Enteral Nutrition. He had explained to Dean that Sam would still be getting his feedings by the NG tube in his nose but now his nutrition and various supplements were in a large bag that administered the tube feed solution over 8-24 hours and they did it in the evening while Sam slept. Dr. Finley and the dietician felt that Sam also required mid-day feedings, too. So, Valerie would administer intermittent gravity drips of feed solution over 30-60 minutes over lunch time. It was a modified solution as to not overload Sam with certain supplements. He was also allowed to have bolus feedings once or twice a day as needed that were administered over 15-20 minutes.

Sam had begun sleeping a lot the last week but he seemed to be awake in the afternoons and Dean wanted to spend every moment he could with him. Sam had trouble moving himself and needed help turning in bed to avoid bed sores. He could still manage a word or two when he wanted and once in a blue moon a fractured sentence which Valerie had said at this late stage was a rare gift. Their father had packed a bag and left a couple days ago. He was meeting Cole to follow a lead to a potential location but he hadn't said anything other than to call him if Sam got worse or something happened. John had been straight with Dean and Bobby. This potential location may not pan out but John just simply felt like he had to do something, so he was going with Cole, but if the location didn't pan out he intended to come home and wait until Cole knew for sure where to locate what they needed, what Sam needed.

"Hey Sammy, it's nice out today you want to go outside?" Dean looked hopeful but Sam shook his head lethargically and Dean cast a worried look to Valerie. She simply offered a slight supportive smile. "There's a nice breeze outside Sammy. Just the kind of weather you like." In the last week Sam had preferred the bed over his wheelchair and he was no longer able to support his weight on his own legs at all anymore. Valerie had said 'spaghetti legs' as she called them were common in late stages of PSP. "No?" Dean tried to keep his voice even and not show the disappointment but it was hard. Sam just shook his head slowly and closed his eyes turning into his pillow and was asleep quickly. Valerie reached out and nudged Dean and then motioned for him to step outside so she could talk to him.

"Dean, it's not you," she assured. "Unfortunately, in stage four of the disease process PSP patients … they sleep more and just want to stay in bed, but make no mistake he loves having you nearby and to have you talk to him. He's still in there Dean but it is not uncommon for patients in this stage of the disease to become withdrawn. The new feedings have helped," she felt compelled to give Dean some good news. "He gained a little weight back," she left it open without a number hoping Dean didn't ask knowing that the small number that it truly was would deflate Dean even more. He didn't ask but just offered a small smile of gratitude to the woman helping to care for his little brother.

Bobby's House, Two Weeks Later, July 4, 2006

Valerie had started her morning shift an hour ago and grabbed an adult diaper to change Sam. He was still sleeping and she hadn't wanted to wake him. Margaret the evening nurse had said Sam hadn't indicated he needed changed all evening and she had decided to let him sleep because he had been restless. Valerie looked at the care notes once again:

Sam had a restless night and appeared to have some grimaces now and again but mostly he had a quiet night. There was no indication that he needed a diaper change. I did check once while trying not to wake him anymore than necessary and he was dry. The evening feeding went well and the full bag was infused. IV hydration was completed, as well. There are additional nutrition notes under the feeding schedule….

Valerie quit reading and closed the library door. This was what she did that let Sam's family know that he was being changed or some other sort of daily care was being done and it allowed Sam the privacy and dignity that he deserved and wanted. "Sam?" her voice was soft and she made an effort not to startle him. "Sam, time to wake up," he stirred at her voice and opened his eyes. "Good morning sleepy head," she smiled warmly. "Let's get you changed kiddo, okay? Start the day off fresh. You've had a lot of fluid over the last few hours, so I bet it's time." She proceeded to removed Sam's evening diaper and stopped. She took her gloved hand and pressed on the used diaper, it was dry. She frowned and looked at her patient. "Sam, do you feel like you need to go? Are you uncomfortable?" He reddened and turned his head away.

"Sam, this is important," Valerie encouraged softly. "Margaret said she didn't think you needed changed last night and you were dry when I left yesterday and turned the shift over to her. Sam?" He nodded and pulled at the sheet to cover himself. "I'm sorry sweetie, here," she answered quietly as she pulled the sheet over his exposed body. "Sam, do you need to go and you can't?" she questioned. She watched Sam's eyes well and saw one hot tear roll down his cheek. "Hey, it's okay honey, I'm going to help, okay?" She walked over to a cabinet they had been using to store medical supplies for Sam and she knew she had some catheters and urine collection bags in the event they were ever needed. "Sam, I have to put in a catheter to help you empty your bladder, okay?"

She inserted the catheter and hung the urine collection bag at the bottom of the bed on a small hook designed for this use. The catheter was doing its job and she saw urine freely flowing into the bag. "Sam, I need to keep that in for a bit, alright?" He nodded. They had been dressing Sam in hospital gowns for a couple weeks now because it was easier to care for him now that he couldn't do much of his daily care anymore. "Hey, how about we brush your teeth, huh? Get rid of the morning grunge?" She knew Sam loved to have his teeth brushed because it was the only time other than when his mouth was swabbed with oral care swabs that he actually was able to taste anything, to feel human. He could still swish the cold water around and spit into a basin, although his spitting had slowly become more of a lean over the basin and let it fall out. She always made sure the water was clear before she had him stop rinsing.

A short while later, she put away the toothbrush and walked over and brushed Sam's hair. "You know my husband used to have hair like yours when we met," she mused. "He says he's thinning out a little," she laughed. "I call it bald, but I love him anyway." Sam smiled at that and moved his lips to try and say something but it came out as a garbled hodgepodge of indecipherable words. "Sam, it's okay sweetheart," she assured. "Maybe, later the words will work for you, just be patient, morning are a little rough at the start for you, remember?" she knew he was frustrated and she wished she could do something more for him but being there for him and helping him understand what was happening to his body, his mind was what she could do and most of all she could be there for him and his family. She had may have one bedridden patient but in reality she had three other patients, as well, Sam's family. She leaned over and looked the collection bag and her eyes she did a double take. She looked at her watch and consulted her notes on what time the catheter was placed and she noted that in just a little over an hour she had collected 1400cc's, her mind thinking one thing, Sam was experiencing urine retention. "Sam, I need to make a phone call, alright? How about I let Dean know we're all done in here?"

Sam nodded and she opened the library door. She walked into the kitchen where Dean and Bobby were sitting with their morning coffees. "Hey, Val, all done with Sammy?" Dean smiled at the nurse.

"Dean, I put in a catheter, so Sam could empty his bladder," she decided cutting to the point was best as she wanted to call Dr. Finley.

"What? Why? He just goes in his …" his voice drifted off. He hated saying diaper.

"He's experiencing urine retention, but it can be handled with a catheter. I placed it just a little over an hour ago and then finished with out morning routine and the urine bag has collected 1400cc's."

"Is that bad?" Dean felt his heart begin to pound against his sternum.

"It just means he's been holding for a while Dean. It's a lot of output for such a short amount of time. His bladder was very full. I'm going to call Dr. Finley and see what he'd like for me to do. He may come to examine Sam or ask us to bring him town. He's okay Dean, he's not in any pain now that his bladder is empty and I told him I'd send you in, so you can see him. He nodded to let me know he wants you in there," she grasped Dean's forearm and gave a reassuring squeeze."

"If he needs to go to town, let me know, I can get the car ready," Bobby chimed in. There were preparations to make whenever Sam went out that made his travel as comfortable as possible. Valerie nodded and went to the phone.

Meanwhile, Greene Memorial Hospital

Dr. Finley had been paged that he had a phone call, so he went to his office to answer it. "Hello, this is Dr. Finley."

"Dr. Finley, this is Valerie, Sam Collin's care nurse…"

"Hi Valerie," he offered amicably. "Is there a problem with Sam?" he sat a little straighter in his chair. He had become fond of the young man and it seemed whenever Valerie called there was a problem.

"I had to place a catheter this morning because it had become obvious that he hadn't urinated in a few hours and he was showing a little discomfort in his sleep. In a little over an hour the output was 1400cc's…" she heard a sigh on the other end of the phone.

"Sounds like he has some possible urine retention happening. I'd like to see him and unfortunately I think this warrants an office visit where I can fully check him out."

"I thought you we're going to say that," Valerie replied. "I'll get him ready and we'll be there soon."

"They'll page me when you get here. It's a light day but it is July 4th so I expect things to pick up later tonight, but right now things are pretty open, so we'll get Sam right in," he never tried to make Sam wait in the waiting room long because it appeared that the more advanced the PSP became the more he was upset by too much stimulus, loud noises, crying babies, so he tried to make his trips as comfortable as possible.

"Thanks." Valerie hung up. "Bobby?"

"Yes?"

"He wants us to come in…"

"No problem, I get the car ready."

"How ya feelin, kiddo?" Dean asked and reached over and caressed his brother's cheek with a thumb. Sam leaned his head into the touch and Dean felt his chest tighten. He couldn't help but notice the urine collection bag and could see that it was a little over 1400cc's now but just barely. "So, Val tells me we might have to go see the doc today to get you fixed up, so you don't have to keep this catheter in … how's that sound?" He placed his hand in his brother's a Sam squeezed it and Dean knew he understood.

"Hi Guys," Valerie kept her voice light. "Well, I guess we're going on a field trip to see the doctor in town. He's expecting us," she assured. "Dean could you step out while I remove the catheter … I'm not keeping it in for the trip."

"Yeah, sure, I'll just be outside Sammy," he assured as he left the room. The door closed and Dean leaned his head against the thick wood, his heart in his throat and fear slivered up his spine causing him to tremble for a moment. This wasn't a bad sign … he had to believe that … this was another easy fix like the UTI … should he call their dad, his mind reeled with thoughts … he pressed the palms of both hands against the door and closed his eyes for a moment and pushed his fear back into its cage for now.

To Be Continued