I watched a man try to die Saturday night. He didn't succeed. Or maybe he was trying to live, and he did succeed. I don't think we'll ever know.
He is 46 years old. He was diagnosed with Stage IV colorectal cancer in December 2005 -- after a normal colonoscopy in 2003 and rectal bleeding for a few months leading up to December -- and had liver metastases at the time of diagnosis. He was found to have lung mets shortly thereafter. Within six months he had his primary cancer resected and had a colostomy bag for stool collection. His cancer has been refractory to treatment.
He is a hospice patient. Essentially, that means he is no longer receiving therapy for his cancer and is opting for comfort care only. He carries a "Do not resuscitate / Do not intubate" order.
He had a "seizure" early Saturday morning, though, and presented with acute-on-chronic mental status changes. He wasn't coherent enough to talk to us; he lay on his side on the bed with his head hovering an inch above the pillow. If you told him to put his head down, he would. But only for a minute, before he lifted it back up. His wife said that he had had a slow decline in the past few months; he called the telephone the remote control and couldn't remember things anymore.
He probably had brain metastases. His family chose to change the goals of care and wanted his acute problems worked up and treated, so we complied. But he was still DNR/DNI.
His potassium was dangerously low, which could have killed him. Unfortunately, if we replaced it too quickly, we would also kill him. So we were slowly replacing it, but in the meantime it was wreaking havoc on his heart. He was going into ventricular tachycardia repeatedly with recurrent "seizures" that, once we saw them, were diagnosed as ventricular tachycardic convulsions, not true seizures. Then he went into torsades de pointes. Repeatedly. I guess I should be grateful for the teaching aspect of the case; if he had been a "full code," we would have been all over him with electrical defibrillation and anti-arrhythmic drugs. Instead, I got to see nature at work, and I promise you that I will always be able to identify torsades on an EKG strip now. Somehow, he kept pulling himself out of these crazy rhythms and was managing to keep breathing sufficiently enough to oxygenate his organs. We kept the potassium running as quickly as we could.
The question was whether he was dying because his potassium was too low or because his cancer had finally gotten the better of him. At first, we thought it was the potassium. But as he kept deteriorating despite potassium replacement, we felt sure it was the cancer. Then I got sent home for the night -- sent home early, didn't have to sleep in a disgusting call room. I was a little reluctant to leave, feeling a very strong desire to watch this man die or live, whichever he was going to do. But I was also bone tired and barely functioning. And it's uncomfortable to stand at the door of a patient's room and watch him convulse while staring at his monitors and listening to his wife plead with him not to let go. So I went home. As luck would have it, I didn't have to go back until today, and I was sure he was not going to be on our list anymore. But there he was. It was the potassium after all, and the drips finally caught up with his deficit and he pulled through Saturday night. He's not cured; in fact, now we're even more sure that he does have brain mets (they're not showing up on his scans, though) and he's going to die very soon, whether it's a few days or weeks or months. He still doesn't put his head on his pillow. But at least now he will probably die peacefully, and hopefully at home, instead of in the hospital.
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On my throne. As it will be someday.
On my throne. As it will be someday.
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- Holly Cummings
- little fish in a big pond or big fish in a little pond? how about big fish in a big pond?
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3 comments:
On some purely intellectual level I understand that the human body is a machine. And on that same level I understand that is the role of a doctor to be knowledgeable about the functioning of that machine. But I don't know how you continue to function, yet alone learn, when faced with something like this. Watching a human just break down in front of your eyes. I think that I would be reduced to curling into a ball and rocking back and forth.
A fundamental thing that all medical people go through is how to suppress their emotions when they need to. Some people choose to never let their emotions come up, which isn't very good, but most people just learn to handle it. A common observation is that doctors often use morbid humor to deal with things -- horrible to do in front of patients, and pretty bad even among themselves -- so there are some people who are encouraging physicians to open up more.
In some ways, I was more detached watching this patient because I knew there was nothing we were going to do -- no magic drugs, no shocking. So there was nothing to do but watch, and try to learn what I could -- although I guess I could have gone somewhere else entirely and not watched at all. On the other hand, it was also more emotional because I knew there were things that we could have been doing, if the patient had wanted it, and instead he was (I thought) "just" going to die. It's hard to suppress that urge to jump in and be helpful.
I don't really have any explanation, other than we all somehow develop the ability to detach when we need to. And I understand that it's shocking, horrifying, and untasteful to other people to learn that about me/my colleagues. I am sure that if you had to, you could do it, too, but I also deeply respect that you might do everything in your power to never have to develop that ability. I don't deny that I'm in a bizarre situation.
I suspect that the ability to detach as you describe is something that most people could develop, at least to an extent. It seems to me that training doctors would be a good use of that ability, and there might be a few more. I suspect that developing it for use in other situations is extremely dangerous and responsible for a great deal of tragic violence. I think it certainly takes a strong ethical sense to develop that ability in a responsible way.
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