Last night I met the patient who’s probably going to be the first to die while I’m actually taking care of them.

Mrs. Buckley is in her 80s. She and her husband are still living in their home. Yesterday morning she suddenly collapsed, in the middle of a sentence. CT scan at the ER didn’t show anything remarkable, although by this time she was intubated and barely responsive to painful stimuli. An emergency MRI was arranged, and I caught up with her in the radiology suite, as Dr. Isakson had sent me to see her right away. The main thing to be seen were her eye movements, constantly rolling back and forth, back and forth, unfocused, unaware of surroundings. The nurses and I were very puzzled by this, but Dr. Isakson later dismissed them as “roving eye movements,” indicating brainstem function without cortical input.

I went to talk to her family and try to get some more history. They were all sitting in a small “family room” in the ER (why are the family rooms always dark brown and green, with low lighting? I wonder whether this color scheme helps, or not). In spite of myself, it was a rather dramatic entrance, because they all thought I would have something new to say. . . And all I could do was ask her poor husband to relive his last moments with his wife again.

Dr. Isakson broke his rule, and looked at the MRI pictures as soon as they were done, before seeing Mrs. Buckley. Now, when an elderly person drops down and doesn’t regain consciousness within a few minutes, it’s never a good deal. For Mrs. Buckley, it was a very bad deal. The entire front half of her brain was dark: no blood flow, totally ischemic. The MRA (angiogram) confirmed the unbelievable: both internal carotids were completely invisible. Only the vertebral arteries were visible, joining into the basilar artery that lies at the base of the brain and feeds the brainstem. The only possible explanation was that one carotid had become chronically occluded, and then that day a clot from somewhere suddenly occluded the other side. The end. (It would be too improbable for two such huge clots to enter both carotids at once.) Once she was settled in the ICU, we found that her neuro exam matched pretty closely: absolutely no cerebral function, and already a few brainstem reflexes disappearing.

Then Dr. Isakson had to talk to the family. As a neurologist, he must have to do this very often, deliver bad news with a bad prognosis and very little possibility of recovery. That’s why I’m puzzled by how diffident and uncomfortable he still seems. I mean, I don’t suppose you should ever become happy with telling such bad news; but he seems unusually ill at ease and uncertain.

Mr. Buckley was sitting on one side of the room, and hardly spoke at all during the whole meeting. His daughter seemed to take over for him, asking questions. After Dr. Isakson had repeated for about the third time, in simpler words, that Mrs. Buckley had had a massive stroke and was unlikely to recover very well at all, her husband suddenly covered his face with his hands and started crying quietly. Seeing this strong old man so broken, I felt like crying too. (Alice, what do you think you’re going to do in a surgical/trauma ICU if you start crying every time someone’s family does?) Dr. Isakson broached the subject of DNR, and the family briefly decided not to come to a conclusion until the other children’s flights came in. Then the daughter stood up and announced flatly, “I want to see my mother,” and walked out. End of meeting.

This morning, the brainstem reflexes that were present yesterday are becoming fainter. Sometime this afternoon the family will probably understand and accept the message of finality that the nurses and doctors are silently communicating, and decide to withdraw care.

I don’t know what to think. On one hand, watching the family’s pain, I’m wondering how I can stand this, for the rest of my career, reliving my grandparents’ deaths in imagination with every episode in the ICU. On the other hand, as one of my friends said when I showed her the MRA, “It’s a pretty good way to go.” Suddenly, no pain. I think her family will agree, when they’ve thought about it for a little while.

Advertisements