Medical Diaries: MICU
This was written back when I was a senior resident working the medical intensive care unit.
The ICU pager on the waist of my scrubs rang again. This inevitably means that somewhere, something very bad is happening to someone. The person initiating the page may be a nonchalant ER physician, a confident nurse, or a very frightened intern realizing that for the first time they are watching someone die. Often though, it is far less dramatic, and the cascade of actions it initiates are routine.
On this night, the number on the screen indicated the ER was calling me. I called back. “This is the MICU.” “Pete, it’s Rick. I’ve got a rather unfortunate lady down here with a history of metastatic breast cancer. Her family brought her in for…”
The story he told in crisp medical phrases was not unusual, and quite sad, despite the routine rhythm of the medical history. A middle-aged woman with breast cancer had just been diagnosed with new metastatic disease in her liver and had been restarted on chemotherapy. Her family brought her to the hospital because in the few days since her chemo, she had become lethargic, confused, and looked ill. Now, oncologists are often given the reputation of not communicating fully with their patients, a reputation which is, like all stereotypes, a bit true, but often largely unfair. In this case, it was clear that the family did not fully grasp the gravity of the patient’s condition. It would be unfair to blame this entirely on the oncologist. Denial, as it takes place regarding illness, is a wide and deep conspiracy. It involves a doctor trying to find the best time to communicate information that is not entirely clear, in such a way that the patient and family are able to receive it. Often, an attempt is made to minimize discomfort. Nobody is comfortable hearing very bad news, and no one in the conversation is exempt from discomfort, uncertainty, or denial.
The patient arrived in the ICU followed by a few of her many family members. Their loved one was moved in a fast and precise danse macabre from the gurney into her bed. She was rapidly attached to heart and oxygen monitors, and a rectal temperature probe was inserted. She became surrounded by more and more strangers, largely of a different race, and had the remainder of her clothes cut off. By the end of this, she looked fully like a patient, tucked into a hospital bed, attached to the hospital itself, her vital signs seen on monitors all over the ICU.
Then came my turn. This was not a “code blue” situation involving people yelling “get me an ET tube, STAT!”, just a routine medical admission for a particularly ill patient. After performing a physical exam, looking at x-rays and CT scans, and thinking about her laboratory values, I had an opinion. Conspicuously absent from this evaluation was a history of the current illness as told by the patient. She was largely incoherent. The work up revealed that for whatever reason, this woman was in liver failure.
Every organ is important in its own way. When the kidneys fail, the body cannot balance fluids and toxins, and the patient dies. That is, until dialysis became widely available, and kidney failure became an inconvenience, limiting quality and duration of life, but not usually killing someone outright. The liver is a different story. If your liver fails, you have three choices: first, you can get better spontaneously, as often happens in diseases like alcoholic hepatitis; second, you can die slowly, hoping for a liver transplant, as often happens in cirrhosis. Third, you can die quickly. A transplant can restore a nearly normal life in many conditions. Of course, you must meet certain qualifying conditions to be on a liver transplant list. People with widely metastatic cancer are not considered for transplant, as they are very likely to die of their cancer, and are unlikely to survive the brutal procedure. It is considered an inappropriate use of a limited resource.
As I sat at the nurses’ station and considered all of this, my duties had grown considerably. Not only must I try to save this patient, but I must also decide if this is even possible. I must also communicate this to the family, the patient if she awakens, and the patient’s usual doctor.
The patient at this point we will name, as the process up to this point has emphasized her dehumanization. We will call her Mrs. Addie. She is the mother of many, with a husband suffering from severe Alzheimer’s Disease. Until about a week ago, she believed her cancer to be largely under control. Her children were all quite young, and few of them had much education. I approached them about what we call “code status”, that is, if she were to have a cardiac arrest, what should be done. While this may seem like an easy question (answer: save a life), it is quite complex. In many clinical situations, a cardiac arrest is how someone dies (in fact, it is how everyone dies), and a decision should be made regarding the likely utility of futility of attempting resuscitation. The default condition is to “do everything”. This includes electric shocks, intravenous drugs, surgical placement of large intravenous lines at the bedside, insertion of a breathing tube, and various other procedures aimed at regaining control of a failing body. On television, this inevitably leads to the heroic medical team saving the ailing patient and receiving the tearful thanks of a grateful family. In real life, that could happen. Most of the time, however, it involves 30–40 minutes of choreographed chaos, resulting in the failure to save the patient, or sometimes, saving the patient only to have them linger for days to weeks in the ICU until they ultimately complete the dying process.
Many people have strong opinions on how they wish to be treated at the end of life. Most religions have acknowledged that futile efforts need not be continued indefinitely. At one extreme is the average nurse, who often half-jokes that she wants to tattoo “DNR” (Do Not Resuscitate) across her chest. At the other end is the family that wishes their nearly brain dead loved one to continue indefinitely on a breathing machine, never again to regain consciousness.
This is a serious moral question discussed several times a day in hospitals by doctors and nurses, but rarely addressed by doctors and patients outside the hospital. It is very difficult to inspire hope in a patient while asking them how they wish to die. In this case, Mrs. Addie had not specifically discussed this with her family or her doctor, and as is usual in these situations, she could not speak for herself.
I gathered what family was around and explained the gravity of the condition. Because of the liver failure, she was bleeding, comatose, and likely infected as well. I told them that we would spend the night doing everything possible to reverse her bleeding and infection, but I could not stop her liver failure. They would have to discuss what she might wish to have done in this type of situation.
Anger, sadness, despair, more anger, disbelief — all poured down on me. Mrs. Addie had always told her children that everything was going to be alright. Her family and I were saved from more contentious confrontation by the obvious fact that they and I both cared about what was happening to her.
I informed the family that they would have to appoint a contact person to collect questions and answers from us, and that we could meet all together in the morning.
The morning brought further deterioration of Mrs. Addie, but no meeting. Some of the family was having trouble accepting the sudden change in their mother, and was nearly feuding with the rest. I assured them all that she was not at this point suffering, and I was still doing all that was in my power to keep her going, including consulting her oncologist and a liver specialist. They agreed to try to meet again the next day.
Mrs. Addie could not wait. Everything we did was ineffective. Finally, her heart went into an unstable rhythm, and I was forced to shock her. I placed the paddles on her chest, pressed the buttons, and delivered electricity across her chest. Mrs. Addie rose slowly to a sitting position, a look of fear on her face, and muttered “Jeeasssusss!” and fell back into her coma.
The nurses and I all looked at her and then at each other. At this point, I felt I had violated my oath to do no harm. I had undertaken what I believed to be an ultimately futile measure, and caused the patient a great deal of pain thereby.
The family was now divided into two camps, one that wished us to continue on, the other that wished us to let her die “a natural death” and to minimize discomfort.
I decided to take a risk. I called them together and told them the story of the shock. “If I thought this was going to save her life and let her come home, or even let her wake up and say goodbye, I would do this all night. But at this point, I am doing it only to delay her natural death. Of course, I will do whatever you think she would want, but you must understand what continuing this way involves.”
Shameless manipulation to get my way? Or, maybe, my way of punishing them for what I felt they were forcing me to do to her? Perhaps, but I did feel that it was in the best interest of my patient, who I am sworn to help. The family came to rapid agreement, and we backed away from our aggressive medical approach. Her pastor was called. The patient died 48 hours later in her sleep, with her family and pastor at her side.