The horror of it all. It was one of the most inhumane situations I had ever been placed in as a physician. Where end of life ethical issues took a back seat to a warped legal driven fear that consumed physicians and nurses alike at the expense of allowing a compassionate natural dying experience. There is a fear of legal retribution that drives doctors and nurses to create great pain and suffering at the hands of irrational families with unmanaged expectations.
I've been a hospitalist now for seven years. One of my responsibilities as a hospitalist is to respond to all code blue situations, otherwise known as cardiopulmonary arrest. The code team usually consists of a doctor (hospitalist or emergency room doctor), advanced cardiac life support nurses (usually from the hospital's intensive care unit), a charge nurse who documents the sequence of events, a respiratory therapist and even a pharmacist. Many students from all walks of life will also get hands on experience in these high octane situations.
Many factors determine whether someone will survive a code blue situation. Recently, we saved a woman after she aspirated into into a pulseless electrical activity rhythm. After ten minutes of resuscitation, we got her back, only to have her die several days later. Some patients and families understand the realities and limitations of the human body. Just the other day, one guy died peacefully in his sleep after living with emphysema the greater part of his adult life.
I've been a hospitalist now for seven years. One of my responsibilities as a hospitalist is to respond to all code blue situations, otherwise known as cardiopulmonary arrest. The code team usually consists of a doctor (hospitalist or emergency room doctor), advanced cardiac life support nurses (usually from the hospital's intensive care unit), a charge nurse who documents the sequence of events, a respiratory therapist and even a pharmacist. Many students from all walks of life will also get hands on experience in these high octane situations.
Many factors determine whether someone will survive a code blue situation. Recently, we saved a woman after she aspirated into into a pulseless electrical activity rhythm. After ten minutes of resuscitation, we got her back, only to have her die several days later. Some patients and families understand the realities and limitations of the human body. Just the other day, one guy died peacefully in his sleep after living with emphysema the greater part of his adult life.
And then there are the end of life ethical issues which arise when families have lost all touch with reality. Such as performing futile CPR on a dead heart. There were seven intravenous drips running through her heart to try and keep her alive.
She was definitely at the end of her life. After several massive heart attacks in recent months, she was left with an ejection fraction of under 5% from which to maintain perfusion to all the organs in her body. For all intents and purposes, she had a dead heart, with just one small thread of a coronary artery surviving her years of hard liquor and tobacco abuse.
But her heart was not her only issue. If cardiogenic shock wasn't enough to initiate compassionate end of life care in this woman, she also had anuric renal failure and was on continuous dialysis. Not to mention she was also in septic shock from severe bilateral pneumonia and required four vasopressors to barely maintain adequate perfusion pressure. The nail in the coffin was her serum albumin level of 1.3, which itself is a life threatening prognostic indicator.
She was the epitome of end of life. Her care was futile. You can't get any closer to death than this lady did. And her family wanted everything done. That's what their mother would have wanted, they said. They demanded full support at all costs regardless of the therapeutic expectation for recovery. It was really quite sad. Dialysis? Of course. Intubation? Not an after thought. Chest compressions? The thought of stopping never crossed their mind.
I couldn't be more certain of her imminent death. I indicated that death was imminent and no reasonable physician could expect another physician to continue full supportive therapies or to do CPR on a dead heart. It was simply inhumane to code a dead heart. A dead heart. A dead heart! Just having this discussion seems asinine to me. The fact that anyone would even contemplate such an action speaks volumes
She coded again. Again and again. The code was futile. The whole thing was ludicrous. Coding a dead heart. A dead heart! I kept saying it over and over again out of disgust for the whole situation. She coded again, and again, and again. Over the course of an hour, she coded five times, and every time the nurses ran in doing chest compressions and pushing epinephrine, despite the fact that she was already maxed out on an epinephrine drip. All because the family wanted everything done.
After hard fought negotiations with the family, they agreed that should she code again, the only appropriate end of life ethical decision would be to let her pass inone peace. And when she coded again, I had to stand there and watch my patient's son holding her hand, surrounded by a massive pile of IV poles, a ventilator, a dialysis machine and ten other nurses and doctors while she slipped back into ventricular fibrillation. And what were his last dying words for his mother? Were they "I love you mom"? No they weren't. They were:
She was definitely at the end of her life. After several massive heart attacks in recent months, she was left with an ejection fraction of under 5% from which to maintain perfusion to all the organs in her body. For all intents and purposes, she had a dead heart, with just one small thread of a coronary artery surviving her years of hard liquor and tobacco abuse.
But her heart was not her only issue. If cardiogenic shock wasn't enough to initiate compassionate end of life care in this woman, she also had anuric renal failure and was on continuous dialysis. Not to mention she was also in septic shock from severe bilateral pneumonia and required four vasopressors to barely maintain adequate perfusion pressure. The nail in the coffin was her serum albumin level of 1.3, which itself is a life threatening prognostic indicator.
She was the epitome of end of life. Her care was futile. You can't get any closer to death than this lady did. And her family wanted everything done. That's what their mother would have wanted, they said. They demanded full support at all costs regardless of the therapeutic expectation for recovery. It was really quite sad. Dialysis? Of course. Intubation? Not an after thought. Chest compressions? The thought of stopping never crossed their mind.
I couldn't be more certain of her imminent death. I indicated that death was imminent and no reasonable physician could expect another physician to continue full supportive therapies or to do CPR on a dead heart. It was simply inhumane to code a dead heart. A dead heart. A dead heart! Just having this discussion seems asinine to me. The fact that anyone would even contemplate such an action speaks volumes
She coded again. Again and again. The code was futile. The whole thing was ludicrous. Coding a dead heart. A dead heart! I kept saying it over and over again out of disgust for the whole situation. She coded again, and again, and again. Over the course of an hour, she coded five times, and every time the nurses ran in doing chest compressions and pushing epinephrine, despite the fact that she was already maxed out on an epinephrine drip. All because the family wanted everything done.
After hard fought negotiations with the family, they agreed that should she code again, the only appropriate end of life ethical decision would be to let her pass in
Son: Can't you just shock her one more time?She left this earth without an ounce of dignity. As a whole, our fear of end of life ethical issues allowed her son to demand a medical assault on her soul to a degree I had never seen before. It was the worst end of life experience I had ever seen.
To which I responded
Happy: No sir, I can't. Your mother is dead.
