“We are in middle of a pandemic. The decision you make is not just about your family member,” I yelled into the phone. It was the only way I could be heard through my respirator helmet.
The patient in question was in his 90s with progressive dementia and multiple chronic conditions. Since December, he hadn’t been able to make it more than a few weeks without a fall. The palliative-care assessment from his last admission gave him an estimated life expectancy of “weeks to months.” Everything I saw on examining him told me it was now days. Soon he wouldn’t be able to breathe on his own.
I described to his granddaughter the discomfort of having a ventilator pump air into one’s lungs. I explained that such measures would only prolong his suffering. Still, she insisted that her grandfather be kept “full code” and have “everything done.”
Three days later, the patient went into respiratory distress. Since he was full code, his sudden decline activated a rapid response, which meant all nearby personnel — doctors, nurses, respiratory therapists and techs — rushed to the room to resuscitate him. The inpatient doctor called the family again. This time, they agreed to make his code status D.N.R., for do not resuscitate. But the patient had turned out to have Covid-19, and the family’s DNR decision came only after many staff members were exposed reviving him.
He died the next morning.
The whole ordeal made me wonder why people insist on futile care even when it comes at a risk to others. But the more I reflected on that question, the more I began to see I was not immune to letting sentiment cloud my judgment.
I recently had another patient who was having difficulties breathing. He was in his 80s, had relatively few medical problems and was completely lucid. He began telling me about his heritage (Italian on his mother’s side), his family (happily married for over 50 years with an adult son who lived nearby) and his career (a public servant forced into early retirement by politics).
He was impossible not to like. So when his heart began to give out suddenly, I found it difficult to speak to him about his code status. The human in me desperately wanted him to walk out of the hospital in a few days. The doctor in me knew he would not survive. How does one convey hope and reality in equal parts in such circumstances?
To make matters more difficult, the patient could not hear me well without his hearing aids. “If you go on the ventilator, you will not likely come off it alive,” I shouted over and over, each time more loudly than the last, not knowing which words he actually heard. Then, while we were having this discussion, a commotion developed in the room across from us. Three staff members in full hazmat gear rushed inside while others crowded just outside the room’s glass door. A few minutes later, we could see the patient, an older woman, lying motionless with a tube coming out of her mouth that attached to a ventilator. “Is that what you want?” I asked.
There was a look of recognition in his eyes. “I don’t want to be on the ventilator,” he said to me clearly. I designated him D.N.I., or do not intubate, but I had no reserve left to talk to him about D.N.R. I placed a central line in his right internal jugular vein, started him on a drip to maintain his blood pressure and sent him up to the I.C.U.
I learned the next day that he revoked his D.N.I. overnight and was intubated. What had changed in a few hours? Did he really understand what was happening? If he had discussed his code status with his family and primary care doctor, would he have made the same choices? Perhaps I should have been clearer about his prognosis.
As E.R. doctors, we usually treat first and ask later. Who has the time to call three relatives to confirm code status when the patient in front of us is fading? And if the patient is stable enough to be admitted, we tend to punt the time-consuming discussion to the inpatient team. But we’re living in a different time.
I’ve seen more people die in the past six weeks than in six years of practice before Covid-19. At the same time, Dr. Robert Redfield, the director of the Centers for Disease Control and Prevention, has already warned about a second wave coming in the fall. Many of us on the front line have been enduring long stints in hazmat suits and forgoing water and bathroom breaks to conserve personal protective equipment. We’ve also been more conscious about our medication choices to reserve sedatives for ventilated patients.
Nevertheless, these small adjustments may not be enough.
A few days after my patient went up to I.C.U., I logged in to a virtual meeting with my colleagues to discuss end-of-life care. We acknowledged that we’d reached a critical point in our health care system. We could no longer afford to “do everything” and “save everyone.” But what was the alternative?
We were not trained ethicists or legislators. We were doctors — doctors who follow the rules, doctors who were taught to value all life equally. How were we supposed to decide who gets a shot at being revived and who doesn’t?
Yet we reached a consensus rather quickly that patients who were found without a pulse, given the oxygen deprivation to their brains, did not have a chance at meaningful survival. We agreed we should focus our attention and resources on cardiac-arrest patients who received CPR right away because they were more likely to have preserved brain function. It seemed, at least for the moment, that we could navigate these complicated matters after all. That was until one of my colleagues asked, “What about pediatric patients?”
I put my microphone on mute and cried.
Since that meeting, I’ve tried to be more proactive about end-of-life discussions. But it’s difficult to open a dialogue when one side comes to it blindsided by his or her condition. Patients are often surprised by how sick they are, and their families are horrified of having their loved ones die alone. Often, I see fear in the eyes of those gasping for air and hear pain in the voices of adult children, asking me how long their mother or father has to live.
I know what they seek from me is reassurance, so it feels wrong to bring up code status. And after having these conversations multiple times a shift over the whirring of my respirator helmet, a part of me just wants to give up and tell them what they want to hear. But then, I remember the lovely man I had sent up to the I.C.U.
Inpatient records show that as his condition worsened, he grew increasingly agitated on the ventilator. So it fell on his family, who could neither visit him at his bedside nor gather in another room, to make decisions about withdrawing life support. Those wrenching conversations now take place over the phone or, if they are lucky, by video call. His wife and son came to a consensus about withdrawing support only after multiple phone calls with palliative service. He died a week into his hospitalization.
If I could go back in time, I wish I could give that patient a hug, hold his hand and listen more attentively to the stories he was sharing with me. And during the time I spent putting in his central line, I wish I had told him the truth: You are going to die, but I’m here with you.
Yoojin Na is an emergency room doctor and writer.
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