Wednesday

What ceremony do we owe our patients?

Today I had one of those stereotypical ICU days...the kind we spend a lot of time as a society talking about on TV and in the news media. A patient is admitted after being found unresponsive at an assisted living facility. They are on anti-coagulant therapy, and you now where this is going. Those medications, for all their tremendous benefit, come with a real risk of harm. I am wary of writing these words for fear that people I know may refuse aspirin or coumadin therapy. That's not the point. The point is that, as physicians, we must continually reevaluate the need for such therapy as our patients age, and to remind them to take fall precautions at home.

The patient is admitted with massive bleeding in the brain...everywhere. I hate to say it, but this was an ideal learning opportunity for me because I got to see the coma exam in detail. (Actually, it's a short 3-5 minutes. As the Attending explained to the family, the brain is like a mushroom with a cap and a stalk. The cap is your cerebral hemispheres and the stalk the brainstem. Coma happens when either you lose both of your cerebral hemispheres or your brainstem. The exam checks for the integrity of these systems in very simple and elegant ways.) There was no hope for "meaningful recovery" for this patient, or any recovery at all.

So out we go to find the family. I read in an article today for class that spoke about the minute-to-minute "micro ethical" decisions we physicians make. And so the first one was to speak only with the family members in the room, and not to wait for the other ones who had stepped out to get a coffee. The second one was to have our discussion not at the patient's bedside. The third one was to have The Conversation in the hallway of the ICU, and not in the small waiting/consultation room.

The hospital is a living organism. It is never for a moment still. I think as an Attending you may forget this fact because you have learned which monitor beeps mean danger and which ones can be ignored. As a trainee, I lack that skill and I know the family does too. We focus so much on our message and the process of delivering it, the immediacy of the decisions to make, that the speaker forgets to attend to comfort. But I suspect for the family it was like it was for me. Try as you might to forget your body when you are sitting for an exam or preparing to speak in public, the opposite happens. It is usually in moments of greatest concentration that the body breaks in - you become obsessed with your need to pee then and there or the new sound of blood running past your ears. It is hard to concentrate on these difficult discussions as the hospital whirls its physiology past you - the monitors beep like a heart, housekeeping whirls like the blood and urine, the nurses' and doctors' conversations break in like random thoughts.

Would it have been better to have chosen the opposite of everything we did? Should we have spoken at the bedside or in the waiting room? Should we have waited for the other family members? Would that amount of ceremony and solemnity have made the message too difficult to take? Was it better to force the reality of the ICU - the activity, the noise - on the family to drive home the point that this is what it could be long term if you choose...?

In the end, the Attending did a masterful job. He was clear and precise and anticipatory. There is no pain without your cerebral hemispheres, and so things will remain comfortable as long as we need. I takes experience to explain these matters, and I am certain I would have talked my way into crying were I in his shoes. As bleeds into the brain continue, there comes a point at which expansion is needed. As the skull is bone and hard, the only place for the brain to go is down into the spinal column. And this wreaks havoc on the life centers of the brainstem and the heart rate goes rogue and wild. And so the Attending explained far more delicately than I have that a cardiac arrest was possible as we waited for the patient's unofficial proxy to arrive, and that a full code would not change the outcome. And that now was the time to think about this possibility of DNR, while a decision could be made later. And I wanted to kill the ICU resident who would continually interject in a futile attempt to force the family's hand. Medically, we all know what is best. Patients simply do not understand how brutal and violent CPR is and how undignified it is to die with unnecessary broken ribs. But medically best is not always emotionally right.

This post is long and a downer, I realize, but it is important that we continue as a society to dialog about end of life care. Someday I will write about being a woman in medicine, but for now I will close with a short observation. I work with a team that is exclusively male. I have found neurology to be unexpectedly male-dominated. Why is it, then, on the three rotations where I have worked with largely male physicians (trauma surgery, orthopedics, neurology), that patients look at me when they are about to cry? And then they do...