‘Grey’s Anatomy’ Season 18 Finale Is a Mass Doctor Exodus (RECAP)

Grey's Anatomy Season 18 Episode 20 Meredith Helm Nick
Spoiler Alert
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The two-part Grey’s Anatomy Season 18 finale shook up the Grey Sloan power structure more than any other of the medical drama’s episodes! Yes, these 399th and 400th installments of the ABC series — Episode 18, “Out for Blood,” and Episode 19, “You Are the Blood” — had enough promotions and resignations to keep the hospital HR staff working overtime.

[Warning: The below contains MAJOR spoilers for the two-part Grey’s Anatomy Season 18 finale, “Out for Blood” and “You Are the Blood.”]

The two-parter starts with a classic Grey’s nightmare: Meredith (Ellen Pompeo) being tormented by nightmares of her mom, Ellis (Kate Burton), haranguing her in the ER.

Suffice it to say, Mer has a rough morning, and she’s not the only one. Winston (Anthony Hill) is still hung up on his brother scamming both him and Maggie (Kelly McCreary) out of thousands of dollars, even though Maggie just wants him to drop it. Amelia (Caterina Scorsone) is heartbroken over breaking up with Kai. And Jo (Camilla Luddington) is reeling from a night of bad sex with new flame Todd (Skylar Astin). (Turns out, the guy breaks out into post-coital song, and he narrates his entire life. Oh, and he also told Jo he loves her after just one night together.)

And on top of all that, Grey Sloan and hospitals across the country are experiencing an acute blood shortage. The docs are getting blood donations from anyone with a pulse… except, of course, Levi (Jake Borelli), because of the exclusionary and unfair policies that bar men who have sex with men from donating blood. Bailey (Chandra Wilson) does vow by the end of the episode, though, to fight this “hateful, stupid rule” with Levi.

So this would not be the best day for Jamarah Blake from the medical accreditation board to return to give the hospital one last assessment before deciding the residency program’s fate. And yet, Blake is indeed scheduled to come in. When she arrives, Richard (James Pickens Jr.) and Bailey try to talk up their progress toward meeting her requirements, but then Blake sees the residents giving blood during their shifts, and her visit is off to a bad start already. It gets worse when she finds out that Mer has plans to leave, and it gets even worse when she watches Mer fail an ambitious surgery.

Grey's Anatomy Season 18 Episode 19 Richard Zamarah

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That surgery, FYI, is an ex-vivo whipple on Cora, a patient of Nick’s (Scott Speedman). Cora has a tumor at the “juncture of all her major organs,” as Nick tells Mer. And as they brainstorm options, Nick is the one who proposes operating on Cora’s organs outside her body so that Cora doesn’t lose as much blood. But the surgery goes south, and the shipment of blood that could have saved the day gets caught in a truck accident, with bags of blood spilling all over the highway. Mer and Nick move Cora to the ICU to try to keep her stable, but Cora goes into organ failure and dies. And Mer can’t even break the news to Sally, Cora’s aunt, since Sally is too far into dementia to even understand that she has a niece. (Cue more Ellis flashbacks.)

Grey's Anatomy Season 18 Episode 19 Meredith Nick

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Richard is, yet again, mad with Mer, suggesting that she was trying to sabotage the hospital on her way out. (Is he still high off of that cannibis smoothie from a couple of episodes ago?) And even Nick expresses doubts, wondering if Mer really should have waited a few days before operating.

The other patients of the week are two we’ve met earlier in the season: Simon, the man who’s dying of cancer, and Kristen, his pregnant wife. As we know, Simon and Kristen are desperate for him to meet their son before Simon dies, so it’s up to the docs to keep Simon alive until the baby is born. Unfortunately, a scan reveals Simon has even more lung mets. Maggie and Winston talk to Kristen about the possibility of putting Simon on an ECMO machine that would perform the job of his hearts and lungs for him and buy him some time. And even though the ECMO idea might mean Kristen would have to pull the plug on Simon, she agrees. “Simon wants me to tell my son that his dad met him, that his dad loves him beyond the beyond,” she tells Maggie and Winston.

Simon survives the ECMO procedure, but no sooner does he have another touching reunion with Kristen does Kristen start bleeding. She’s having an abruption, and there’s only one bag of B-negative blood left. Simon wants the docs to unplug him from the machine and give the blood to Kristen, since they have the same blood type. Winston grudgingly agrees and runs the last bag of blood to the OR where Kristen is going under the knife. And happily, Kristen gives birth to her and Simon’s boy, Jamal, and survives the childbirth. Winston rushes Jamal back to Simon, and Simon just has enough life left for a few second with his newborn son. He tells Jamal the same catchphrase he shares with Kristen: “Hello forever.”

The fourth patient of the week would have been Rosie, a Marine with pulmonary fibrosis, but we never actually saw her. Instead, we meet John, her husband, who has been referred to Owen (Kevin McKidd) by Heather Young, the wife of one of the veterans to whom Owen gave life-ending drugs. Now John wants Owen to do the same for Rosie, who’s dying a painful death. But now that Teddy (Kim Raver) has gotten Owen to realize he’s endangering his whole family by breaking the law — even out of the most merciful of intentions — Owen refuses to continue the scheme. But John says that if Owen doesn’t give Rosie the drugs, he’ll report Owen for his crimes.

Owen goes to Teddy, and he and Teddy meet with John together to propose moving John and Rosie to a state where physician-assisted death is legal, but John refuses. So Teddy tells him that they can’t help him. And sure enough, John heads right to Bailey’s office and tattles on Owen.

When Bailey finds Owen and Teddy, they’re packing up their stuff, getting ready to flee the country. Bailey is enraged that Owen would put the entire hospital in jeopardy, especially now that the residency program is already close to extinct. And by the way, who’s watching the trauma pit?

Enter April Kepner (Sarah Drew)! Yes, as you’ve seen in ABC promos, April and Jackson (Jesse Williams) are back in the 400th episode. And April walks into the attending lounge for coffee just in time for Bailey to put her in charge of the pit. And when Ben (Jason George) pulls up with the truck driver from the crashed blood truck, April jokes that she’s like a Pavlovian dog when it comes to Bailey: “She yells, and I snap to attention.”

Unfortunately, without a supply of blood, there’s not much April can do, so she shuts down the ER and donates blood herself. Amelia finds her there, and after they greet each other and catch up, April gives Amelia a pep talk about the Kai situation. “Sometimes love comes back around,” April says. (Yes, she and Jackson are very much back together and even kissing in the hospital elevator again.)

As for Jackson, he’s back in Seattle to talk to Blake about the residency program and how the Fox Foundation is giving the program even more funding to keep it going strong. But Blake isn’t convinced, and she’s especially irritated when Jackson tries to do spin control about Meredith leaving.

And while we’re on the topic of Jackson, Catherine (Debbie Allen) makes both him and April deliver eulogies for her as she gets another round of chemo. Catherine wants a preview of her funeral, you see. But Amelia tells Catherine that those funeral plans are premature: Catherine’s tumor is responding to the clinical trial, and Catherine is “living from cancer and not dying from it.”

Grey's Anatomy Season 18 Episode 20 Catherine

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OK, enough with the tangents. Back to Owen and Teddy! Bailey, still angry with them but now a little more empathetic about their scheme, tells them that she has to call the cops but that she has a blood shortage that will take up the next few hours of her time. In other words, she gives Owen and Teddy a few hours of a head start before she calls in their crimes. Owen and Teddy flee, narrowly avoiding a run-in with the cops in the hospital hallways. A very confused and concerned Amelia bring them their kids at Joe’s Bar, and the last we see of Owen and Teddy, they’re on a plane, ostensibly taking a sabbatical and traveling to Egypt to see the Great Pyramids. (At least, that’s their cover story.)

Amelia heads back to the hospital and runs into Link (Chris Carmack), and she apologizes to Link for blindsiding him and breaking his heart. She’s on the other side of that equation now, and she is reminded of how much it hurts. But Link doesn’t hate her. He’s grateful to her for giving him a son who brought light into his world. In fact, he even says he loves Amelia, but “just not in the painful way anymore.”

Grey's Anatomy Season 18 Episode 20 Link

Lilane Lathan/ABC

And then later that night, Kai shows up in the hospital parking lot, telling Amelia they couldn’t sleep. As in, they couldn’t bear being apart from Amelia. And they start making out.

Speaking of romantic reunions, let’s talk about Maggie and Winston! Stunned by Winston’s anger about his brother, Maggie tells Winston in this two-parter that she feels like she doesn’t know him and that maybe they got married too quickly. But at the end of the finale, Winston tells Maggie that he never really understood love until he met her, and he didn’t tell her that he loved her lightly, and he didn’t propose lightly. He says that they have to protect their love now, because love like theirs doesn’t come around often. And that’s all Maggie needs to hear, apparently, because they start kissing, too!

As for possible romantic reunions, Link finds Jo — who ended up splitting with Todd — in the hospital nursery. And Jo proposes that Link come home with them and that they indulge Jo’s daughter, Luna, in watching Encanto for the 57th time. “Everything is so screwed up in this world that I need us not to be,” Jo says. Happily, Link agrees.

Grey's Anatomy Season 18 Episode 20 Jo Maggie Link

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And that’s just about where the good news end. The bad news is that Blake shuts down the residency program, telling Bailey that the hospital is a dysfunctional family where Richard doesn’t respect Bailey’s authority as chief of surgery and Meredith doesn’t respect Richard’s authority as chief medical officer of the Fox Foundation. She’s also appalled that Meredith went forward with Cora’s operation even amid a blood shortage. So Blake says Bailey has to “rebuild” and “recalibrate” the program from scratch, and by the way we see Levi and Helm (Jaicy Elliot) cleaning out their cubbies, it seems like all the residents are out of a job.

Also out of a job? Bailey! She finally reaches her breaking point in this finale and gives Meredith the keys to the chief of surgery’s office with a you-broke-it-you-fix-it edict. Yep, Bailey is quitting as chief, effectively immediately.

Jackson pleads with Mer to take over as chief — if only on an interim basis. And as Mer contemplates the prospect, Nick finds her and says that he might have been wrong about doubting her Cora decision. But Mer is still hurt that he didn’t trust her judgment, and she tells him to go back to Minnesota, especially because she has “a lot of work to do” at the hospital now. Nick slinks off, and Mer has a rush of flashbacks — as we see clips from prior seasons in reverse chronological order. Finally, Mer sees a vision of her younger self just outside of Bailey’s office, on the other side of the glass. And younger Mer looks most disappointed in her older self. So real-time Mer rushes out of the office and calls Nick’s name, but it seems the good transplant doc is gone.

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So, who will be left standing when Season 19 premieres this fall? Is Bailey gone for good? Have Owen and Teddy bid Seattle a permanent farewell? Does Richard still have a place in the hospital? Will Levi and Helm find another job there? It’s going to be one long hiatus before we get answers.

Grey’s Anatomy will return for Season 19.