Agraphia Medical Tragicomedy

19May/103

Dust To Dust

I apologize for the number of times I've talked about death recently.  It's not so much morbid fascination or curiosity, but simply a reflection of the rotation that I'm on.  In the Medical ICU our team's mortality is approaching 60%, and since we round on these patients - and consequentially, their caring families - every day, it's hard not to find meaning in death.

Last night a very young gentleman died, but the cause of his fulminant liver failure remains unclear.  We suspect he may have had a rare condition that is nearly impossible to diagnose, but until the autopsy comes back we won't know.

As I walked by his room, the arterial line monitoring his blood pressure caught my eye.  In the Emergency Department we only measure blood pressures every 5 minutes or so with an external cuff; in the ICU an "art line" lets us watch the blood pressure in real time from a catheter placed directly in the arterial system.  I watched, a sick feeling in the pit of my stomach as his systolic blood pressure lazily swung down from 80... to 79... to 76...

My attending was at that moment talking to the family, explaining to them the futility of his care.  We were trying to convince them to change his code status from FULL CODE to DNR, so that we would not need to start CPR on his already frail body when he died.  He was actively dying; no matter how badly we wanted to, we could never cure him.

He was on the maximum doses of 3 different pressors - medications that keep blood pressure artificially elevated - and we knew that instantaneously on stopping them, he would die.  Unfortunately at that moment, as I was watching his systolic blood pressure hit 63... 58... I knew we had no time left for long discussions.  If he flatlined before the family agreed to his DNR status, I would be obligated to start the code.  That was a violation of his body I did not want to perform.

Nervously, I waited.  54... 49...  43...

And then my attending rounded the corner, his arm around the mother's shoulder, her head low, gait unsteady, sobbing.  He nodded to me as they walked in the room; crisis averted.  It is a small accomplishment every time we allow a death to occur naturally in the ICU.  I sincerely believe it's the right way to let people with end-stage conditions go, but it can be exceptionally hard to explain this to families.

I sat at the nurses' station, watching the remote monitor.  With every heartbeat, a soft *bing!*

*bing*  *bing*  *bing*

And then a pause.  One more halfhearted *bing*, and it stopped forever.  A wail from his room, first quiet, then louder and torrential; a mother's love, devastated.  I watched the EKG tracing for quite a while, the fine, flat line devoid of life.  What once was and now is not.  Dust to dust.

Life is short.  Live it while you can.

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  1. That’s got to be a tough rotation.

  2. I’m with you. Having death so close and so real makes you think about it more than is probably healthy. Having these discussions wipes me every time, somehow it doesn’t get easier but seeing a family at peace with the last days and hours is so much easier to handle than messy arrests and an undignified end. enjoying your blog anyway:)

  3. “It is a small accomplishment every time we allow a death to occur naturally in the ICU.”

    I’m nitpicking here, but a natural death in the ICU is oxymoronic. Your statement illustrates how deeply expectations of extreme life-preserving measures are embedded in our Western medical care culture. I understand your point that dying during a code is the furthest thing from a natural death, but dying while on 3 pressors is hardly natural. I’m glad to see increased emphasis on training physicians to have DNR/DNI discussions with patients well before an acute need for resuscitation arises.


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