Agraphia Medical Tragicomedy


It’s OK To Die

This month I'm rotating through the Medical ICU, which means that I deal with a lot of death. I suppose over the last few years I've learned - had to learn - to be comfortable with the dead and dying. I find this extends as well to families. I'd like to think I've learned a few things about how to be caring and compassionate.

I had a phenomenal conversation with a very loving family today. Their son suffered an absolutely devastating brain injury after a cardiac arrest, and has not recovered. Despite everything we could do - and we tried everything - he continues to be completely nonresponsive. It's been a very difficult series of conversations, mostly because they are simply not ready to let him go. Most importantly, he remained a FULL CODE until today, which means a brutalizing, dehumanizing round of CPR, intubation, and caustic medications in a last-ditch effort to restart the heart when, inevitably, he tries to die.

I decided it was time to ask them to come to terms with his injury. I went in to the room and simply closed the door, shut off all the beeping alarms, and the 5 of us sat down together. I asked them to explain to me their expectations, hopes, and fears. I'm not an expert at end-of-life counseling by any stretch, but I do think that having everyone sit and talk takes the edge off.

As I've experienced many times now, with enough talking, the underlying theme arises: they don't want him to suffer. They don't like the tubes, the beeping, and the IVs; but they somehow think that it is necessary. This is just how it is done, and doctors know best. I think it's one of the biggest failures we as doctors perpetrate on our patients. That somehow, against all odds, against complete and utter medical futility, we can save everyone.

So, once they were done talking, I began to explain. None of these tubes are necessary. None of them will change anything. Some of them will make him feel better, so with their permission I'd like to keep those in. Some of them, like the tube shoved down his nose to force-feed his stomach, should go.

And then, the most delicate moment. "There is a lot of misunderstanding about DNR/DNI," I quietly explained, "that somehow it means we aren't fully taking care of your son. What it really means is that when it is time for him to die, we allow him to do so peacefully and on his own terms. The alternative, and what his FULL CODE status currently means, is that when his heart stops beating, we will perform CPR on him for about 20 minutes, possibly breaking ribs in the process, try to establish huge IVs in his groin and neck to push medications, and shove a tube down his throat to force breaths into his lungs. If he were my brother, I would never ask for this to be done to him."

The family was quiet for a moment.

"He would never have wanted that. Please don't do that to him."

They hugged, and shed a few tears. I bid a quiet farewell. I think they'll be more at peace with his passing now.

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  1. Well done. We approach this conversation very similarly, you and I.

  2. I’m glad you took the time to gently explain the situation to that young man’s family. It’s so difficult to have a loved one die, particularly when they’re young and strong, and the event that caused it was unexpected and sudden. And it’s also natural for the family to hang onto hope that somehow, he’ll recover.

    You handled it well. Thank you for your compassion. I’m sure the family feels the same, and they’ll remember you for your kindness later on.

  3. Great job, Zac. Thanks for sharing!

  4. I have a lot of respect for you as an intern going in and having this conversation…It’s funny. We all work in ICUs with attendings and social workers and psych-social who have been doing this for years. And yet, in my experience, both in the hospital and personally, no one wants to even get near talking about this subject…or they wait until the last moment when the family finally brings it up (which I can’t imagine how hard that must be as a family member).

    It’s one of the most therapeutic things a doctor can do for a family and for their patient, so respectable…

    good for you for being the brave soul to say what that family has been wanting to hear; for giving them the permission to entertain another choice…

  5. Yeah, medicine has established those expectations, but it is an unholy triumvirate of media and lawyers that completes the group. We didn’t do it by ourselves.

  6. Outstanding job doc! This is the way to handle the end-of-life discussions that are all to common in the ED.

    My wife and EM doc and I have written a book on this theme….It’s title is …”It’s OK to Die.” Available on your website