The other night I wandered into the ICU just to look around. Our vascular surgeons seem to be going through another AAA phase, with record numbers hitting the door in the last few weeks, and I wanted to see how things were going in the ICU.
I found one of the junior residents, Joe, just getting into a difficult discussion with a patient’s family. He was an old man, with a lot of problems, and this time around they had all caught up with him at once. He was in respiratory failure, on a ventilator; his kidneys were failing, and he had already had one round of dialysis; his blood was filled with a raging infection, which didn’t seem fazed by all the antibiotics he was receiving; his liver was starting to look bad; and the monitors were showing more and more abnormal beats, indicating that his heart didn’t have far to go either. The resident explained to me, behind the nurses’ station, that he had received a very frustrated signout on this patient: “He’s in multi-system organ failure. There is nothing we can do for him surgically, or medically either. He shouldn’t even be in the surgical ICU, since he hasn’t had surgery recently. Just make the hospitalists take him, or something. It’s hopeless.”
Joe was not one to take a passive approach. He decided that since no one else had managed to get very far in talking with the family, and since he didn’t want to be the one running multiple hopeless codes on this old man through the night, until finally he didn’t respond to ACLS protocol any more, he would tackle the job of getting DNR status from the family.
I was frankly curious. Much as I hate to think about it, in four months I’ll be the one left over night with four or five ICUs full of patients, and I’m sure it won’t be long before I run into this problem. I wanted to hear what he said. It helps that Joe is about six foot four, with a quarterback’s build. I don’t think I’ll ever make as impressive and authoritative a figure as he does. He told the son and daughter quite bluntly that their father was in bad shape. He explained how all his organs were failing at once, and went through the list of heroic interventions which were necessary just to maintain the status quo. Then he got down to it. “Your father is not going to survive this. I’m sorry to say this, but he is going to die, soon. The question is, how much more do you want him to go through before he dies? Right now, if his heart stops, we’ll do everything we can, giving him drugs and pushing on his chest. It might work for a little while, but it’s not going to reverse what’s going on here.” Within an hour, they signed DNR papers, and the old man died that night.
I believe that what Joe did was good. He helped the son and daughter understand what was happening, probably better than anyone had before. He helped them come to some kind of terms with their father’s impending death, before it happened. He decreased the patient’s suffering, by not forcing him to go through futile codes, and letting him go a little more peacefully. He helped the surgical team, by solving a problem for them.
I’m sure that within a year, I will do the same thing. But right now, I can’t picture it. I tried to imagine the words in my mind, but somehow, despite how much my understanding of “end-of-life issues” has changed in the last eight months, I still can’t make those pessimistic words come out. I still try to think of what might happen well, how things might turn around. I tried to imagine a discussion about “do not intubate” status, which is an oxymoron and a disaster (how can you code somebody, or even try to do pressor support, if you can’t maintain an airway? it’s useless). Some recent tragedies have demonstrated that DNI status simply ties the doctors’ hands. The patient should be either DNR, if everyone is ready to let go, or full code, if it seems like a survivable illness. But whenever I try to put words to that, I find myself arguing for full code. Maybe things will get better; we shouldn’t give up yet.
I think Joe had it on his list for the night: “Check CBC on Mrs. Adams. Serial abdominal exams on Mr. Jones. DNR status, likely death, of Mr. Smith. . . ” Maybe after I run a few hopeless ICU codes, it will be easier to go hunting for DNR status, just another item on a list.