April 7, 2008

In Print

Spotlight

Upcoming

Student Scene

StudenTalk

Lab Works

Science Progress

Home

Student Scene

Some Gentle Steps Toward Death

Graham Ramsay Erica Seiguer Shenoy

The medical intensive care unit (the MICU) at Massachusetts General Hospital is a world unto itself. As an intern, you are on call every third night for a 30-hour stretch. There rarely is any “down time.” The patients are, for the most part, very, very sick, barely holding on to life, supported by the extraordinary drugs and devices that modern medicine has devised to take over the major functions of the human body.

On my first day in the MICU, I was the on-call intern for our team, which means that in the morning I was responsible for running plans on the patients, and throughout the course of the day and night, admitting patients to the unit and covering all the patients on our team, under the guidance of the junior resident. That morning on rounds, we heard the story of a 70-something-year-old lady who had arrived at around 6 a.m. and was admitted by the on-call intern from the previous evening. She had collapsed at her nursing home, having suffered cardiac arrest, and she had received CPR and been intubated in the field.

We knew little about the events surrounding how she had been discovered, though over the course of the day, we were able to obtain collateral information about when she was last seen well, how she appeared before she became ashen and fell to the ground, and aspects of her past medical history. As we rounded on her early that morning, her daughter arrived and we updated her on her mother’s condition. We explained that she was on many medications to support her blood pressure as well as the ventilator to support her breathing. We confirmed her code status, that is, what she and the family would want us to do in terms of intervening—resuscitation, intubation, and other interventions that may or may not prolong life. At that time, her daughter appeared in a state of shock and grief, having just visited with her mother over lunch the day before. The decision was made to leave every intervention option on the table; she would remain “full code.”

Over the course of the day, the patient at first seemed to be improving. Her “pressor requirements”—the dosages and numbers of medications necessary to sustain her blood pressure—declined, and through a variety of studies, we were able to rule out some possible etiologies of her presentation.

We still, however, did not have a clear explanation for her continued poor cardiovascular and respiratory status. There was no evidence of infection (though we were covering her broadly with powerful antibiotics); there was no evidence she had had a myocardial infarction, and no evidence of a cerebrovascular event such as a stroke. Despite this, we knew that her neurological status was severely compromised: she was not withdrawing to painful stimuli, her oculocephalic reflex was absent, pointing to brainstem injury, and her oculovestibular reflex was likewise absent.

Yet as evening progressed, her pressor requirements increased to the point that we were using four different medications at escalating doses, without any appreciable effect on her blood pressure, which remained dangerously low. I spoke with the junior on the team, and we called the senior resident who was on call. The senior resident in the cardiac intensive care unit also stopped by. We went through the case, the pertinent labs and imaging studies and the current situation. We spoke with the ICU fellow. The junior asked me to call the patient’s daughter.

It’s not an easy conversation to have—to tell a person that a loved one is dying. In the cases this past year when I have had to do this, I’ve approached it in the way I would hope a doctor would if the tables were turned: I am honest, laying out the facts—what happened over the course of the day, the approaches we have tried, and the gravity of the situation.

I do the same on this phone call, at around 1 a.m. in the morning. The daughter asks if she can come in later in the morning. I resist the temptation to say yes and let her know that the nature of the situation is such that I fear her mother may not make it until then. I also tell her that we are reaching the point where there may be little we can do to help her mother. As it is, we are using very large doses of the medications available to sustain her blood pressure, and it’s not clear even this will hold her.

An hour or so later, her daughter arrives and I go through the situation with her. The nurse taking care of her mother is also there. The daughter is considering changing her mother’s code status to CMO, comfort measures only, in which we would withdraw life-sustaining interventions such as pressors and the ventilator, and make her comfortable. We all know that death will follow soon after. The junior joins in and we discuss what we do know about her mother’s condition and what we don’t know. I think the latter is one of the hardest things to convey to a family. There seem to be very few certainties. We hold on to the facts and acknowledge the limits of our abilities to predict the response to intervention, the likelihood of recovery, and what kind of quality of life might be expected.

The daughter makes the decision I thought she would, which is to acknowledge the limits of modern medicine and the human body. She is crying, but says, with conviction, that she knows it is the right thing to do. We explain to her what we are about to do and ask her to step from the room for a moment; then we turn off the monitors, remove the patient from the ventilator and stop the pressor medications. Her daughter is with her at the bedside when she passes, within minutes. “She looks peaceful,” she says to me. I perform the task of pronouncing the woman dead. As the daughter leaves, she stops to embrace the nurse, the junior resident, and me.

—Erica Seiguer Shenoy, MD–PhD ’07, is an intern in internal medicine at Massachusetts General Hospital.

top

Copyright 2008 by the President and Fellows of Harvard College