As a medical student, we’re “taught” how to act when during patient death: how to actually perform the necessary exams, how we are supposed to treat the deceased and, to a much smaller degree, how to interact with the loved ones. I went through this. I saw my share of patients who died during my rotations. This story is in that vein, but unlike all the ones I “treated” as a medical student, this patient is the one I claim as my first death. He was mine from evaluation in the ER, to care in the ICU, to the end. So here goes… “Time of death, sixteen hundred.” It’s such an easy statement to make, 5 short words, but, in the understatement of all understatements, that simplicity belied the enormity of the situation. He was 47. He spent his last ten days in the ICU, most of that heavily medicated and intubated. When were finally given permission to initiate comfort measures, he lasted ten hours. I remember getting paged down to the ER from the call rooms. My PGY-3 and I were having a normal call night, 8 admissions, 2 deaths, so we knew this would be something “good.” As was my privilege being the intern (and with no medical student), I was the first at bedside and I remember thinking “This guy is sick as sh*t.” Pick a system and he had a pathology. Cardiovascular-EF of 15%, Respiratory-pulmonary edema, Hepatic- ascites, Renal- AKI; all of this on top of his current IV and intranasal drug use, with a MAP in the 50’s and a GCS flirting with intubation. After he bought himself an intubation and I had a crash course in vasopressors, we got him up to the floor and the chart biopsy began. “There’s no way this is accurate.” 47?! But there it was in the chart, in black and white. He had what one of my attendings referred to as “city mileage”. The shine was off this apple. Ten miles of hard road. Whatever metaphor you use, this guy had had a rough go. Discharge from the hospital the week before for a similar admission, and a few weeks before that, and before that, each time flirting a little more with that point of no return. Then there was the flood of consultations, specialist visits…basically everyone but the plumber had had their hands on my patient. While reading through, the words “FULL CODE” glared bright red from the top of the screen. I found a note that the patient’s mother, who happened to be his medical power of attorney, wanted to be contacted for any admission, at any time. So a la “no one calls at 3 am with good news” I called her at 3 am and explained the situation. “Do everything to keep him alive and we’ll be in in the morning.” “Do everything” turned out to be not much at all, that night at least, and the shift passed without further incidents, the patient stable on 5 of levophed. That next morning went smoothly, the patient remained stable and was even intermittently interactive during my exam. Rounds were similarly tranquil, save for palliative medicine showing up to inform me that they had scheduled a meeting with the family in a few days time and needed someone from the treatment team there. “No problem”, I thought as I walked out of the hospital. “He’s sick, definitely, but stable, interactive, piece of cake to update them.” I hadn’t counted on how much could change in the next few days. Walking in the next day, feeling refreshed, I walked onto the ward–and was caught dead in the glare of one of the off-going nurses. “Don’t even get me started on” (stabs a pointed finger behind her) “your patient” as she stalks off…perfect. The night team wasn’t looking any more happy, though they explained what had happened in a little more detail. Apparently my patient decided that he was stable enough for extubation, completed such successfully, and then quickly dropped his MAP into the 30s and required five different vasopressors to bring his blood pressure back to “normal” ranges. Thus began the daily dance of the hypotensive…slowly weaning off one at a time until the patient cramps and then starting all over again. It became a dance for us: drop the neo, drop the EPI, drop the dobutamine, drop the vaso, drop the levo (or it would have, if we could even have kept him off the EPI, more commonly it was drop, drop, up, up). The only thing that dropped in the next few days was the amount of propofol needed to keep him down. Every time his MAP would drop, another call to mom, letting her know the news and trying to prepare her. Finally, the day of the palliative consult arrived. It was the case manager, the mom, three sisters, and serving as the medical expert…me. I’d been briefed on how to handle these cases minutes before by the palliative team, and I thought I knew how I would expertly share the details of the patient’s prognosis, and what our recommendations would be. I deftly described the five pressors needed to keep him alive, the respirator, all of it. What I got in return was “When God wants to take him, there’s nothing you’ll be able to do. Keep him alive.” So we added a new step to our daily dance. Drop it down, bump it up, call the mom, “Keep him alive.” So it went for two more days, until the patient’s mother pulled me aside, visibly distraught. “You all keep calling me, multiple times a day, telling me my son’s going to die, that you think he’s only got a few minutes left, and yet he’s still here. I can’t handle all this…” As she started to cry I gave her some time to collect herself and said “Ma’am, you’re making the decisions about his care. You have to know everything that’s going on in order to make the best choice for your son.” By this point the patient was no longer requiring any sedation and showed no interaction during our frequent checks, and after sharing this information, she decided to have another meeting that afternoon, with some more family from out of town. We had a new attending on by this point, one not known for mincing words with families, and I thought it best to spare them from his…honesty, so I once again volunteered to lead the talk. I started the same way, catching everyone up on the details of his case, how much intervention he was requiring to keep him alive, the usuals. I sat back to answer any questions, but this time the family quickly jumped to “letting him go”…all save the one vote that mattered. She still wasn’t ready. She was all alone and needed to make the funeral arrangements, find a plot, all the unhappy trimmings that come with burying a loved one. The emotion escalated rapidly and I excused myself to let them hash things out, leaving word that I was immediately available if they needed me. After about thirty minutes I got the call. They were ready. At this hospital, the routine is to disconnect all the medications, turn the monitors off in the room (no one really needs to hear the flatlining family member), and giving space. Because of how tenuous he was, we kept the pressors on, all five of them, until everyone had a chance to say goodbye. As the nurse halted the medication flow, I told the family it could be any minute. His blood pressure dipped, and then his MAPs climbed into the 70s and stabilized. His blood pressure was suddenly better with no intervention than with everything we were throwing at him. I posted at a computer just outside the room, sure that this was a last rally and I would be needed momentarily to declare. I sat there working; the bat phone went off, calling me to another crashing patient. I came back. I waited. I was called away. Another new rhythm we developed. I was finally called by one of the nurses to inform me that he had died and I needed to pronounce him. He had lasted ten hours. “Time of death, sixteen hundred.” As one of my attendings put it, “We often cannot do anything to save a life, but we can definitely prolong a death.” Source
