[Triage Note: faint carotid pulse on arrival; witnessed collapse while eating; 6 epi’s en route; intubated at present; PEA x 30 minutes; 500 N.S. bolus by EMS; 8.0 ETT oral intubation]
It’s Sunday evening. I’m explaining to a patient that his illness is viral – that he will likely feel better within the next day or so – when the overhead page arrives: “Emergency doctor to resuscitation room B.” I excuse myself and walk quickly to the other side of the department.
As I enter the room, paramedics are lifting a lifeless body onto the stretcher. The story begins: “Eighty two years old, from a nursing home. Severe dementia. He was eating dinner and started choking. Staff started CPR, and ten minutes later, the ambulance arrived.” An endotracheal tube is secured in the patient’s mouth, as a paramedic pumps oxygen through the tube, into his lungs. Thick secretions block the movement of air. A stream of vomit flows from his lips onto his cheek. His eyes are open and fixed toward the ceiling. His corneas look like shriveled contact lenses. Squiggles on the cardiac monitor are disorganized – no meaningful heart rhythm. A nurse puts a finger on his neck, as I put one on his groin. We say it in unison: “No pulse.”
Another doctor is at the head of the bed, flashing a light into the man’s pupils. “Fixed and dilated. No reaction.”
“Any advanced directive?” I ask.
“None,” the paramedic says. “Full code.”
“Start CPR.” A nurse thumps his frail chest and drugs are ordered. I squeeze a blob of gel below his sternum and sink an ultrasound probe into it. His heart is still beating. It’s a panicked flicker, rather than a confident thump – but it’s still going. “Continue compressions, and give another round of epinephrine.”
Finally, a chart arrives and I have the patient’s name. “Are we sure there are no advanced directives?” I ask. The paramedics explain that there were no specific instructions from the nursing home. I ask my assistant to look up his medical records – there aren’t any – he’s never been to our hospital before this. A name is listed as “next of kin” on the chart. Under relationship, it says “other.” I call the number and find that I’m speaking to the patient’s niece, or second cousin – even she isn’t sure about the exact connection. I explain the situation.
“Oh dear,” she says. I ask if she has the patient’s Power of Attorney. “No,” she says. “As far as I know, it’s the Public Trustee.” I ask if there are any other family members. “Only distant relatives,” she says. I thank her and tell her that the patient is on life support and that there doesn’t seem to be any chance for meaningful recovery.
“From what I can tell,” I say, “he was without oxygen for too long. There’s no brain activity.”
“Oh dear,” she says again. “I’ll let the other relatives know.” She thanks me and hangs up.
After the second round of epinephrine, his pulse returns. A nurse has a finger on his neck. “Strong carotid pulse,” she says, stepping back and pushing a button to inflate a blood pressure cuff. I lift his wrist. His peripheral pulses are back as well – those furthest from his heart – and they too are strong. A good blood pressure reading pops onto the monitor. His vital signs are stable. For now. An organized cardiac rhythm beeps along the screen. I ask the nurse to print an ECG. Within seconds, it’s in my hand.
He’s having a heart-attack. Such events are usually amenable to urgent treatment in the catheter lab. I page the Cardiologist, but before he calls back, I ask a clerk to call the office of the Public Trustee and Guardian.
The Cardiologist calls back and I explain the situation. “If his pupils aren’t reactive,” he says, “I don’t see much point.”
“I don’t either,” I say, “but the decision isn’t mine to make. He’s still alive. At least his body is.”
“What do you think we should do?”
I look to the clerk. “I’m trying to get a public trustee so we can cease resuscitation.”
The cardiologist agrees, but five minutes later, he calls back. “Did you hear anything?”
“No public trustee available on Sunday,” I tell him. “I have to keep him on the ventilator until someone says we can take him off.”
“Tough case,” he says.
An hour later, while I’m suturing a drunk woman’s scalp, the nurse calls again. “His blood pressure is dropping.”
“Okay,” she says, “but we’ll need a central line.”
I feel like I’m working on a corpse, threading a large intravenous line into his internal jugular vein as the ventilator heaves periodically. Someone has taped the man’s eyes closed. It’s shift change, and the newly-arrived nurse and I chit-chat about our kids. The dopamine is kicking in. His blood pressure is once again stable.
The April 1, 2014 issue of the Canadian Medical Association Journal reported that ‘Technology-laden end of life care is associated with poorer quality of life, lower satisfaction of care, and increased anxiety and depression in family members.” The article goes on to say that “Advance care planning can increase the quality of life of dying patients, improve the experience of family members and decrease health care costs.”
Two days later, I search for the man’s death summary. I can’t find it. Instead, I find additional investigations, including a head scan which only confirms what we’ve known all along: There is no brain activity. In the Intensive Care Unit, I find the man still on life support. The attending physician hasn’t been able to secure sufficient documentation to withdraw treatment. “We’re working on it,” he says. “We should be able to withdraw by this evening.”
“Just out of curiosity,” I ask. “How much has it cost to keep him here. ”
“Ballpark?” he says. “Fifteen thousand.”
Several hours later, withdrawal of treatment is agreed upon. The tube is removed, his breaths slow, and within the hour, he passes away.
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Great post, Raj.
This happens too often, and you’ve captured it so well. I worry that our failure in these cases gets twisted to support euthanasia weeks before these patients present to the ED.
Just because we have the technology doesn’t mean it should always be employed. There is grace in dying peacefully when it is one’s time.
I thought Nursing Homes mandated DNRs?
Hi Brenda – nope – no mandated DNRs. All patients and their POAs have the right to choose.