Death

One of my patients might die tonight. I think the chances are greater than not that she'll survive the night, but there's a real chance she might die. She has relapsing Burkitt's lymphoma and HIV, both diagnosed in September, and she has failed all of her chemo. She has only a short time to live (like, weeks), and I'm OK with that. What I'm not OK with is that I left this evening without being sure of what her wishes are. When she was admitted last night, she was a "full code" -- wanted everything done. As of an hour ago, she's a "DNR-A" -- "do everything except CPR." The attending signed the DNR order after talking to her. But I don't know if he actually talked to her about it. And I wouldn't even have thought to question it except for something the nurse said to me. (And in his defense, he had talked to the patient about it before, in the office, but the papers had never been signed. And I'm not saying that I think the patient actually wants CPR; she knows the extent of her disease as well and is very realistic about it.) But I didn't have the guts to go back into the patient's room and confirm with her in person that these were her wishes. Because she's already been crying all day, and I didn't want to see or hear her cry again. And that's what's bothering me about it. From a technical standpoint, if she dies tonight, it's not really my business, because the papers are signed and the orders are in, and I'm not there tonight to have to deal with it as it unfolds. From a guts standpoint, it IS my business, because I am one of her doctors now, too, now that she's in the hospital, and it's my job to talk about code status with patients, and I hate doing it, and this is a near-worst-case scenario of what happens when I try to ignore it. So if she dies tonight, I'm going to keep wondering if she really really truly didn't want CPR (even though I know this is objectively the best decision). And if she's alive tomorrow, am I going to be able to make myself talk about it with her?

Another woman might die tonight, too. She's in the ICU. She delivered her baby 6 days ago. She has swine flu. She's the third H1N1 case in our hospital this month; the first two died. All the cases have been obese, and all have had a history of asthma. But the first two I didn't know the name of, and no part of their care. This woman I found out about because everyone in the OB/Gyn department got an emergency page yesterday to go to employee health to get Tamiflu. Since I'm on medicine right now and not OB/Gyn and I wasn't exposed to her, I'm not at risk. But since I'm on medicine right now, I was around when the infectious disease team pulled her chest x-ray up on the computer this afternoon and I saw it. It's one of the worst chest x-rays I've ever seen. And then I asked the ICU team (which I'll be joining in one week), and they said she was intubated today and could seriously die tonight. I don't know why it's bothering me so much; all I've seen of her is a chest x-ray. But since she's post-partum, she could be one of my patients. And since she's in the ICU, she'll be my patient in a week, if she's still alive. I don't even know that it's her baby I'm thinking of (the first time I can truly say that I'm acting like a "mommy doctor" instead of a "baby doctor," as most people like to characterize the profession. I'm thinking about her -- the "sickest person in the hospital," according to one attending. And me.