Dr Death

Over lunch this week, my preceptor and I headed out into the community to make a few house calls. Yup, you heard right. On occasion we hit the road to visit patients who can't make it in to the office. Or, at least, can't easily make it into the office. This usually consists of palliative care patients and the occasional melodramatic Italian granny who enjoys making a show of staying in bed making enthusiastic proclamations to God and having her extended family wait on her hand and foot.

On this day in particular, the road show consisted of one of each of these typical patients. As we left the home of the Italian grandmother (with a bottle of homemade wine in hand as a token of the family's appreciation) I scanned the file of the palliative patient. A 72-year-old man with a diagnosis of metastatic gastric carcinoma. Since the time of his initial diagnosis he had been through the roller coaster of surgery, chemo and radiation, each treatment bringing the family hope until the test results came back... it was still spreading.

His appearance was startling. His face, gaunt and angular, smiled at us as we came through the door. Snaking out from under the covers were numerous lines, many of which his life was dependent on-- one drain from his peritoneum draining his ascites, one from his chest draining the recurrent pleural effusions, the catheter draining his bladder and the IV replacing all the fluids being drained out. An uneasy balancing act. In spite of the hard round belly protruding from his t-shirt, the skin hung off his bones in the characteristic manner of rapid weight loss and muscle catabolism. With the exception of his grin, he looked as though he had died days ago.

His wife beamed by his side.

"He's feeling much better," she told us, "all we need to do is get him back on his feet!"

My preceptor and I exchanged uneasy looks. He had already briefed me on the fact that the family didn't seem to really accept his dismal prognosis. He gently explained to the couple that he really wasn't expected to get any better, and that we should likely discuss what the plan was if he were to get worse.

"Well, we'd bring him to the hospital!" the wife said, confused. "And take him back here as soon as he improves."

The patient was still full code. Most cancer patients are made DNR long before they reach this point. This man's family wasn't willing to give up their hope for a miracle.

"Oh," the wife exclaimed, "I almost forgot. Our home care nurse was telling us that we should get a referral for Dr. X. She's supposed to be an expert in pain control, and she'll come right to the house."

My preceptor blanched. "I don't think we're quite there yet."

The wife was confused. "What do you mean?"

He backtracked. "I just don't feel that there's anything she can offer your husband that I can't do for you just as well. His pain is well controlled right now. I just don't think he's... sick enough... for that at this point."

My preceptor is a good family doctor. His patients trust him. In this case, his word was enough to appease this family.

In the car on the way back to the office, I questioned him about this. Who was this doctor? A palliative care physician? Why not consult her? Maybe it would save us from driving 20 minutes out of town to check on this man on a weekly basis.

"The family isn't ready for that step."

"What do you mean?" I pressed further, "what could it hurt?"

My preceptor sighed. "Every patient I've referred to Dr. X. has been dead within 48 hours of seeing her."

I digested this information. Then it dawned on me what he was trying to say.

"You mean... she helps them die?"

"I'm not saying that. I have no way of knowing..."

"But that's what you think."

He nodded. "When the family is ready to let go, I'll involve Dr. X. But right now, as long as he's pain-free and the family believes he'll recover, it's not time."

We sat in silence for the remainder of the trip. As much as I believe that people should have the right to end their own lives when they see fit, to be faced with it in reality was awfully sobering.

I still have so much to learn.

The Streak is Dead... Literally

Considering the amount of time I've spent in the Emergency Room, people are often amazed when I tell them I've never had a patient die. Honest. Actually, my life has been pretty much untouched by death entirely (touch wood, quick!). All of my family members who have passed away did so when I was too young to really get it, and no one has died in the past 15 years or so. Colour me lucky. And my patients... well, I guess they've been lucky too. I've had a patient or two die, but it was never while they were actually under my care. And only one of them was a patient that I'd actually had time to get to know beyond last name and chief complaint.

Even when people are supposed to die on my watch, they manage to hang in there until a new team comes on in the morning. A patient can be actively trying to die throughout the day but will miraculously stabilize at the exact moment I accept the code pager. And speaking of codes-- four code blues, four ICU transfers, three have improved well enough to come back to the floor. One is still in ICU, but doing better. No deaths. Un-freaking-believeable.

Basically, if you have a parent in the hospital... you want me on call. Not for my skills, but for my crazy good karma.

Now in all fairness, this might also be due to the fact that since becoming a resident I have actually spent very little time in the company of sick patients. Anaesthesia, Emergency Psych and Obstetrics don't often lose patients. And my time in family medicine was much the same. So the only time I was ever really in danger of losing a patient was during my hellish two months of general surgery and now, in my second month of internal medicine.

Which is why I was a little unprepared when I got called in the middle of the night to pronounce a patient on the hematology/oncology ward. We don't usually cover that ward on internal medicine-- those patients have specialized problems, and are usually handled by the specialists themselves. This was a young-ish guy (in his late 40's) who had developed a particularly unfortunate case of Graft-Versus-Host-Disease after a bone marrow transplant for a rare lymphoma. He had been doing poorly in hospital for over a month, and had acutely decompensated over the past few days. His death was expected to the extent that the attending hematologist had already gotten verbal consent from the man's wife for an autopsy to try to explain his recent rapid decline. All I had to do was pronounce the man dead and fill out the death certificate.

I knew the drill. I had seen it once as a medical student, and I knew the steps in theory. I entered the patient's darkened room and offered my condolences to the family. I then asked them to step out of the room for a moment while I examined their loved one. I turned my attention to the recently deceased. His mouth was fixed open in a silent scream, his head tilted towards the ceiling. Thankfully, his eyes were closed. His hands were cold and doughy. I was hesitant to touch them, feeling as though I were intruding on him at his most vulnerable. I felt for a pulse. Carefully, I peeled back his hospital gown to place my stethescope on his chest. I listened to the silence for a full two minutes, spurred by the irrational fear that if I rushed the process the poor man would sit bolt upright on the pathologist's steel table and I'd be interviewed on the evening news. I heard nothing. No breath sounds, no heart sounds. I tapped on the diaphragm of the stethescope to make sure it was working. It was. He wasn't. I pressed into his nailbed to assess response to pain. I reached over to rub his sternum but stopped-- his skin looked so fragile and delicate that I worried it would tear under my knuckles. Instead, I skipped to the last step. Prying open his dry eyes, I carefully touched a cotton swab to his cornea. No reaction. I gently drew his eyelid shut again.

I left the room. After a few more (likely contrived and artifical) words to the family, I retreated to the paperwork that accompanies death. I pondered over the offical cause of death for what was probably longer than I needed to. The autopsy would provide that information anyway... whatever I wrote would just be a guess. All I could think of was the coroner's talk we had received at the start of residency.

"Cardiorespiratory arrest is NOT the cause of death. Cardiorespiratory arrest IS death."

But I couldn't think of anything else to write.

By the time my shift ended at noon, I had been called to pronounce a second patient. An elderly man on the internal medicine ward with metastatic cancer, who had been bouncing in and out of the emergency room with severe nausea, vomiting and dehydration but determined to live out as much of his remaining days in the comfort of his home. Finally, he gave in and came into hospital to stay. He died with his family at his bedside, a jaundiced figure with a belly bloated with ascites and extremities that had wasted away to skeletal proportions. Although he wasn't 'my' patient at the time of his death, he had been under my care the week before during one of his shorter admissions. I knew him.

I don't know how many people I will have to pronounce during my medical career. I'd rather not speculate. But in the middle of the night in the darkened ward I laid to rest my first patient. And although I've already forgotten his name, his face will stay with me much longer.