Monday, January 11, 2016

Happy New Year! Let's Talk About Death

I've been thinking a lot about death lately.

Admittedly, I do work in hospitals. Plenty of sick patients, and, as they say in Scrubs, sometimes it seems like Death is just another coworker. A coworker we fight against and do our best to foil every day, at every turn.
Recently on the floors, they called a rapid response when a patient displayed seizure activity. I arrived at the scene and heard the story from the witnesses, and got ready to turn the patient on his side in case he vomited. AK, one of my residents, arrived right on my heels, looked at the patient and asked me if the patient had a pulse.

He did not.

I turned him on to his back. She told me to start compressions, which I promptly did. My other resident arrived and he and AK ran the code. I did what I was told, helping to perform chest compressions while another team member breathed for him and another team member drew up medications. We performed CPR until the Zoll monitor told us it was time to shock him. After two shocks, we were able to successfully resuscitate the patient, took him straight to the ER, and from there he went to the cardiac catheterization lab. A couple of days later I saw him in a hospital room, recovering.
He looked awesome. He was relaxed, breathing easily, and did not look at all like the choking, gasping, swollen man I saw on the floor that day.
That's one of those times when it seems amazing, what we can do. We brought a man back to life. And he walked out of the hospital and will go on to live his life. Take that, Death. Checkmate (for this round).

On the other hand, I remember all too well the first time I watched someone die. It was in the emergency room. I was working a night shift during my last month as a third-year medical student. I had just done my tenth rectal exam that week, and was settling in for what I was hoping would be an interesting shift. Well, I got that and then some. She was 93 years old, African American, with several comorbidities. She came in with shortness of breath, and the rest was a blur. She could not maintain her oxygen saturations, but her pre-written advanced directive orders did not allow for transfer to higher level of care. We could not intubate her to give her more oxygen, and more importantly, she did not want us to do that. I don't remember what nursing home she came from, or even what her name was. I remember being told to take her blood pressure, and asking her how she felt. All she did was smile at me. A wan, accepting smile that was weighed down by pain, an inability to oxygenate, and 93 years of life experience. A wry, humble smile that was matched by the dim light in her eyes - a smile that will remain with me for a long, long time. She gave me that smile, and I had no idea what to say to her. All I could do was smile weakly back, and give my best reassuring grip of her hand. That grip of mine, while not the strongest or the largest of hands, usually serves to reassure patients that I'm doing my best for them and that I'm working hard to get them better. But in her be honest, I am not sure who was reassuring whom: The medical student who was doing his best to feign calm, or the elderly lady who was ready to face the next world. Soon her breathing became more labored, and the nurse came to tell us. My attending beckoned me along and we ordered a narcotic pain medication to ease her work of breathing. She got drowsier, and then we just stood there as she breathed her last. Her breathing stopped, her heart soon joined it, and that dim light in her eyes finally dimmed to nothing.
The hardest part was then, we had to just move on. There were other patients that required more immediate assistance, and we couldn't afford to dwell on it at the time.

I recently started listening to The House of God on audiobook. It's my second time with the book, the first time being a read-through in my third year of medical school (shortly before that ER shift), not to mention my repeated viewings of Scrubs, which is loosely based on some of the book's satirical concepts. An OB/GYN attending I once worked with told me I should read the book three times - as a medical student, again as an intern, and again after completing residency. In the first chapter of the book, the chief of medicine illustrates the hospital's mission statement of "doing everything always for everyone forever to keep the patient alive." A lot has changed since 1978, and that policy is not the end-all, be-all it used to be. Now, a part of nearly every History & Physical we interns write is a conversation about what the patient's end-of-life wishes are. Well, it's supposed to be a part of that H&P. Such conversations are uncomfortable for both the physician and the patient, and we often do not like having them. Or, as a palliative care attending I know will tell you, "too many doctors are afraid to have that conversation, or even say the word 'die.'"
Every palliative care specialist will tell you that having that conversation is not, as The House of God states so flippantly, "Getting the DNR." It's about knowing the patient and what they want. How they feel about the end of their life, whether it's coming soon or decades away. It's like getting consent for any other procedure - it's explaining the risks and benefits of cardiopulmonary resuscitation and intubation. And it's about respecting the patient's wishes once they make their informed decision. That doesn't make it any easier to talk about, though.

You know what I remember most about that code? The dull, sickening crunch of the patient's ribs breaking with that first compression. It's a sound I have heard multiple times in codes and, to break any illusion of eloquence, it freaking sucks. We may joke about it, but it's a terrible sound. And granted, sometimes it's a small sacrifice to make to restart the patient's heart. And in this case, he was a young enough guy that he recovered quickly. But sometimes...that's not the case. Sometimes those broken ribs just compound the fact that the patient's heart was only barely resuscitated, and he/she/they cannot be weaned off the ventilator. Sometimes it's that they required CPR and multiple shocks for so long that they suffered anoxic brain injury because we could not get the blood pumped to the brain in time, and for the rest of their lives, they will be unable to tell us anything about their thoughts or wishes.

When someone decides to become a physician, he/she usually does not consider this part. We become doctors "because we want to help people" but in our heads that is often synonymous with saving lives. With performing "heroic measures" to bring patients back from the dead, and watching them walk out of the hospital. Never once do we think about the other side of it. About what to do when people don't want those measures. About how to talk to a family about letting their relative go because he/she just cannot fight anymore, or how to accept that a patient wants to die with dignity and on their own terms rather than facing the possible adverse consequences of our so-called "heroic measures." Because we don't always want to think about that. We imagine the oft-used, "if it was my mother or father" scenario to help us counsel the patients...but in this case, that thought often terrifies us. We can bring ourselves to deal with patient deaths, and shrug those off, but when it comes to our own family, we often feel powerless. All of our medical insight and education becomes clouded as we find ourselves on the patient side. Even in our imaginations.
And that's when we question ourselves. We can't help but wonder if it is worth it (in these particular cases). Are our "heroic measures" there to protect the patient from death, or to protect us, the physicians, from having to deal with death?

The one-line answer is that there's a balance between the two sides of that sentence. 

But there is no easy way to find that balance, nor is there a universal way. But if we as doctors truly want to be the best physicians we can be (and, if that aforementioned palliative care attending has her druthers) - for the sake of the patients - we will never stop trying to find that balance.

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