In the wee hours of the morning, the radio crackles to life: “64-year-old female, lung cancer with mets to bones and brain. Sats in the 70s on 100% O2. Full code. Two minutes out.”
First, do no harm. That’s what I was taught in medical school. So simple. Yet, if my time in this emergency department has taught me anything, it is that medicine is never black and white. What awaits this terminally ill woman upon arrival in our trauma bay? Clothes cut off. Body exposed. Ribs broken. Skin torn and bleeding. Chemically paralyzed, and airway traumatized. First, do no harm.
The patient arrives, starving for air with eyes wild. Alone in a room crowded with machines, monitors and masked faces. I try to smile, to hide the sadness in my soul, for I have met countless patients who walked this road, and I recognize where it ends. Where is her family? “Not here yet, but they want everything done.” They have sent her here for a miracle I know we cannot provide.
But now is not the time for reflection. “Impending respiratory failure — prepare for RSI! The resident will do the intubation.” Propofol, succs. Ear to sternum, head back. In on the right, swipe the tongue to the left. Lift, don’t lever. Don’t touch the teeth! Epiglottis and … there are the cords. Tube! Stylet out! But the tube won’t advance, and the airway is swelling before my eyes. Failed intubation, get the bag! Sats in the 40s, 50s, 60s. Face distorted, squished under the mask. Gown hanging open, breasts flopped out to the sides.
I will apply, for the benefit of the sick, all measures which [sic] are required, avoiding those twin traps of overtreatment and therapeutic nihilism. I took an oath. But what does that mean, when a family is begging you to “do everything”? Where is the limit to “everything”? “Everything” is limitless; yet there are outcomes we cannot prevent. When are you giving up, and when are you accepting the truth?
Second attempt, tube is in. Connect the vent, but the air won’t move. Pressures maxed. Labs are back — lactate 8.8. We’ve lost the pulse. Start compressions! That unmistakable sound of ribs snapping with that first push of CPR. That unforgettable feeling of cracking as you heave all your weight onto fragile bones. Press, recoil, press, recoil. “Stayin’ alive, stayin’ alive” — or is it “another one bites the dust”?
The family is on the phone. My staff takes the call. “Yes, they want everything, and yes, they want her to be comfortable.” I look at this woman, body bony and scarred from her battle with cancer. Tubes and lines running in and out of every conceivable place to put one. Blood dripping from a failed IV attempt. Fragile chest skin beginning to tear from CPR. ET tube taped to her face with pressures on the ventilator that would leave me breathless. Is there anything further from “comfortable”? I am not the omnipotent healer this family is asking me to be.
I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug. Is it being warm, sympathetic and understanding to abide to resuscitation requests knowing that they are near to futile? How do you explain the limits of medicine to a desperate family?
The code continues. Morale runs low. Exhaustion, and sweat drips from the effort of chest compressions. One round, two rounds. Draw more epi. Hs and Ts. Should we lyse her? It’s the only thing left. The family is still on the phone. How do you tell a 90-year-old woman that it is time to let her daughter go?
Most especially must I tread with care in matters of life and death. … Above all, I must not play at God. Perhaps the warmth, the sympathy and the understanding come not from abiding to ill-informed requests but from encouraging patients and families on their journey toward acceptance. Love, comfort, family, friends. Last moments and lasting memories, with no room for ET tubes or chest compressions.
With the prognosis so dire, the family gives us permission to stop. I am simultaneously relieved and devastated. Relieved to stop this fruitless resuscitation, to stop causing even further harm to this patient who has already endured so much. Yet devastated for this mother, who just lost a child, and devastated for this patient, whose life is now behind her. Who will never again see the sun set, or feel that delicious chill of a cool breeze over dewy skin. But most of all, I am devastated for the way this patient’s life ended — with a push of propofol after one last wild-eyed, air-hungry stare around a room full of strangers.
No terminally ill person should die alone and assaulted in a trauma bay.
But now is not the time for reflection: gloves off and back to work.
“Humanities are the hormones of medicine.” — William Osler
Footnotes
CMAJ Podcasts: author reading at https://soundcloud.com/cmajpodcasts/160585-hum
This article has been peer reviewed.
This is a true story. Details have been changed to protect the patient’s identity.
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