Agraphia Medical Tragicomedy

8Feb/11Off

FULL CODE!!!!

Last week a man was rolled in to the ER, although I hesitate to call him a man. He looked more like a mummy; lips shriveled, eyes sunken, arms and legs even wrapped in gauze to cover his numerous decubitus ulcers. He had suffered complete and total anoxic brain injury months earlier; there was nothing left of him but a physical husk. Every single physician and nurse dropped what they were doing to stare incredulously as he was wheeled by. He was death incarnate.

The medics, with a wry smile, handed me his chart from the nursing home. Handwritten, on a single blank sheet on top of the chart was a family member's scrawl, underlined three times and followed by a plethora of exclamations.

FULL CODE!!!!

It became quickly apparent that he was much sicker than his chronic state of nearly-dead. Heart rate was up, blood pressure was down. We sat around for a moment, twiddling our thumbs. He was clearly going to die no matter what we did. The "right" thing to do from a legal standpoint was to rush him up to the ICU, flood his system with antibiotics, take him to the operating room to slice out all of the decaying flesh, and pound him with fluids.

The "right" thing to do from a medical and humane perspective, however, was to let him go. I would add "peacefully", but that opportunity was lost months before when we stabbed a breathing tube through his neck, shoved a foley up his urethra, a catheter up his rectum, and a feeding tube through his stomach in the name of Good Medicine. So, instead, I pulled the family aside to talk about end-of-life care. I wish I could say it went well.

"I'm sorry to tell you this, but there are two ways he can die tonight," I said quietly, "peacefully, with morphine to make it painless and comfortable, or with the ICU physicians cracking ribs during CPR, pushing painful medications through his veins, and shoving you out of the way during his last moments so he can't be with his family."

The daughter looked at me with a distasteful look. "Well, we goin' home, so it's between him and God now," she scoffed, "so y'all better do everything for him. I got faith he'll pull through. Here's my phone number in case anything happens. If it's busy jest call back later."

And so, he went to the ICU. Predictably, his heart stopped beating, ribs were broken during CPR, needles were stabbed into any remaining veins, and no loved ones were with him when he died. The phone was busy. They stopped by the hospital late the next morning with a bag of Dunkin Donuts to sign the paperwork.

Is there a moral here? I'm not really sure. I suppose I can only speak for myself when I say - vehemently - that I would never want to go that way.

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  1. Ugh, what a rough story.

    I guess the question for me is, what would the patient have wanted? If there’s any argument for having an end of life conversation as early as possible, it’s this story.

    Kudos to you for actually making the effort to have that difficult conversation with the family. Hopefully the next time things will be different.

  2. @Steve – End of life conversations are worthless. At the end of the day, it’ll be the family making the decision for you if you aren’t capable of making it for yourself.

    This poor man suffered because of his family, not because he hadn’t signed a piece of paper ten years ago when he was healthy.

  3. A “code” is a medical treatment for specific indications. It is not some magical cure all that everyone has a right to as a last hurrah before officially declaring someone dead. If the medical treatment is not indicated, physicians have no responsibility to give it no matter what patients or families say. We don’t have patients dictate when to do surgery, or antibiotics, or TPA. Why do some suddenly act like this is different? Has TV elevated this medical treatment to the the level of a fundamental right and panacea?

    With the usual caveats of I was not there in this particular situation, I would say that CPR or any type of code would be futile in this case and therefore would not have done it personally as I’ve done in my own practice.

  4. I’ve seen this heartbreaking scene too many times and had the same frank conversations with families who believe their chronically declining and now woefully ill loved ones have a one-in-a-million shot at a miraculous recovery.

    So many people want to “leave it to God” or give their loved ones “a chance to fight” when the only two options are dying horrifically and dying reasonably well.

    It’s demoralizing when an entire team of physicians complies with a request to do everything when there’s nothing left to do that will lead anywhere good. It feels wholly unethical to prolong the pain in folks doing their best to die.

    It also makes me angry that we pour a ton of money into these lost cause cases when I have to beg & fight to get basic insulin for my uninsured new diabetic patients b/c it’s “too expensive” when it will prevent or delay expensive and disabling/deadly complications. We need to prioritize more sensibly.

  5. These situations are very disturbing, and I seem to read about them all the time. What puzzles me is how doctors and hospitals so often feel compelled to agree to a family’s seemingly unreasonable demands. Why is that? Are doctors not within their rights to say no? Is it a fear of lawsuits? A tender-hearted desire to fulfill a family’s wish, however desperate? I don’t understand the source of the doctors’ sense of obligation. In so many other circumstances, doctors do what they feel is best and that’s that. There’s no telling them to do something else. But at the point of death, something changes. ??

  6. Next time just find yourself a ballsy Intensivist and have them make the patient a DNR secondary to medical futility. Works like a charm.

  7. I’m a medical speech pathologist (just stumbled across this blog) and constantly find myself getting frustrated with families that want full code, but no feeding tube. Then they can’t understand why I’m starving the pt to death by making them NPO when they aspirate everything. Just put them on comfort care and I’m happy to let the pt aspirate anything they please.


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