To print this page, select "Print" from the File menu of your browser salon.com > Health & Body March 27, 2000 URL: http://www.salon.com/health/feature/2000/03/27/resuscitate The hardest question Even after doing it hundreds of times, it's never easy to ask someone whether they want you to let them die. - - - - - - - - - - - - By Jeff Drayer "OK, Mrs. Brown, there's just one more thing I want to discuss before I leave you alone for the night." I opened the chart and pretended to read. I always had trouble looking into my patients' eyes during this part. Just stay cool, I thought to myself. This is your job. Nothing to worry about. "Are you comfortable? Do you have any questions about the medications we put you on or the plan for the next couple of days?" I was clearly stalling now. I'd already gone over it all three times. I forced myself to put the chart down. "No," she replied. "I feel much better now, doctor." I smiled glassily. That's what made me hate this so much. "Mrs. Brown," I began, shuffling jerkily toward her bed. "I need to ask you something." Her smile bade me continue. "Now, we think you're going to do just fine and I don't think anything bad is going to happen. We know what's wrong and we know how to treat this. I think everything's going to be absolutely OK." For just an instant I could see the smile waver. She sensed a "but." "But if something should happen. Well, I mean, more specifically, if your heart should stop beating, such that we would need to start compressions and maybe even shock you, like on TV." The smile was definitely gone. "Not that I think that's going to happen. Not at all." I found my gaze drifting down to the floor. "Or if you stopped breathing for some strange reason, which I also don't think will happen, and needed to be put on a breathing machine which we may never be able to take you off of." I forced my eyes back to her face. It was wrapped in confusion and increasing dismay. "Are these things you would like us to do?" I asked, handing her a blue mimeographed piece of paper. "Because if you don't, I'll need you to sign this." She started to read, then stopped. "What does this mean?" she asked. "It just says DNR/DNI." My internship mainly consisted of one uncomfortable episode after another. Informing people of a loved one's death, dealing with difficult patients and staff and being vomited upon were, unfortunately, rather common occurrences. However, the most disquieting part about internship for me was meeting each new patient, reassuring him that we had state-of-the-art facilities and were going to work very hard to get him better, and then asking him to sign a waiver saying whether or not he would desire treatment in case his heart stopped or he couldn't breathe. As the member of the medical team who knew the least (except when we had med students on the team, and even then it was a tossup), it always fell to me to perform the delicate task of discussing do not resuscitate/do not intubate orders. It was a job I feared. After all, patients are admitted to the hospital either for a new and scary disease or an old familiar one that may finally be getting the better of them. It takes a lot of work to calm them down and make them feel safe, which is not just nice for the patient but can actually affect the course of their hospitalization. And once this tenuous bond of trust is forged, about the best way for a doctor to screw it up is by asking a patient if, in the scariest of situations, they'd rather have us help them, or sit by and watch. That's what I had to do, usually about seven times per night when on call, two times a day otherwise. One would think that I'd get good at it, or at least not have it make my hands sweat and my voice shake. But one would be wrong. Still vivid in my memory is Ellen Greenwood, an 87-year-old woman who weighed no more than 70 pounds. She was dying of stomach cancer, and there was nothing that could be done other than try to make her comfortable and see if she'd make it through this episode of internal bleeding. The prevailing thought was that she would not. When I sat there on the nearly empty bed with her at 2 a.m., though, seeing her shivering beneath four blankets, scared to death that she'd never see the outside of a hospital again, I simply could not bring myself to bring up the DNR/DNI form. I knew that without it, we would be legally bound, in the case of an emergency, to perform heroic action for as long as it took until she was absolutely, undoubtedly dead. But I also thought that discussing the possibility of her heart suddenly stopping or her breath no longer coming to her could cause her to have a heart attack right there on the spot. So I held off. She'd at least make it through the night, I thought. At 5:20 that morning, my beeper went off. Terrified in the way that I always was when being awakened by a loud noise, I looked at the call-back number and recognized the sequence for a "code." I jumped out of bed, trying to recall who was in room 1102. But when I arrived to see 11 respiratory technicians, nurses and doctors in frenzied activity around what looked like an empty bed, I remembered. "What happened?" I asked my resident breathlessly. "A-fib," she replied, never stopping the rhythmic compressions she was applying to Mrs. Greenwood's chest. Atrial fibrillation -- her ventricles were squeezing in a random, uncontrolled pattern that would not push blood through her body. I took my place at the head of the bed. With some help from the respiratory tech I got the breathing tube into place, right between her vocal cords, and started pumping air through it with rhythmic squeezes of the big, blue oxygen bag. Air movement could be heard on both sides of the chest, so we knew she was getting the oxygen she needed. Now all she needed was blood flow. Her lips had turned a purplish blue. "What's the story?" I looked up to see my attending, clearly still half asleep despite his drive in from home, taking up most of the door frame. "Eighty-seven, advanced unresectable stomach cancer in a-fib," replied a nurse, filling the last of six vials with blood that was to be rushed down to the lab. "Does she want this?" he asked as a portable X-ray machine the size of a tractor dislodged him from the doorway. Another nurse shrugged. "No orders," she replied, and injected a syringe full of epinephrine in hopes of getting the heart back into a synchronous rhythm. The next 30 minutes involved a set of clearly futile activities surrounding Mrs. Greenwood, not the least of which was my attending screaming at me the entire time that so help him God, if I ever forgot to discuss DNR right when a patient was being admitted again, I'd be cleaning up the colonoscopy suite for a year. I didn't forget. Of course, the odds wouldn't have been bad that Mrs. Greenwood would not have signed such a waiver. Most patients watch people getting healed by electric shock and miraculous injections on TV all the time. What my attending really meant wasn't so much that he wanted me to get my patients' opinions as that he wanted me to convince those people who were very, very sick to sign the form and give away their right to heroic measures. This bothered me for quite some time. After all, the purpose of a waiver form is to give the patient the option of accepting or declining. With my white coat on, I knew I could sway the patient's opinion whichever way I wanted, and that made me feel uncomfortable. But as the year went on and I continued to outgrow the old shoes of the med student and began to fit into my new ones as a doctor, I realized that this was not an issue of me forcing my opinion on somebody, but rather me making just another of what would be dozens of clinical judgments on each patient. And after all, as a doctor, that was my job. So as my internship wound down, I still found a heavy feeling in my stomach and beads of sweat on my forehead every time I broached the subject with a new patient. But I did come to take a more active role as a patient advocate, by giving my professional opinion as to whether it was likely that resuscitation and intubation would be helpful or whether they would artificially prolong a life that had, for all intents and purposes, ended. On one of my last on-call nights I admitted a frail 83-year-old man who had suffered his second mild heart attack in two weeks. He was friendly and outgoing and talked to me of his great-grandchildren for quite some time before I decided to pop the question. If his heart stopped beating or he couldn't breathe, did he want us to take every measure we could to get him going again, even if it meant being on a ventilator the rest of his life? He was very sick, I reminded him. I had checked his EKG, and it showed a very ominous pattern. He was in extremely poor health. He paused and thought, for only a moment. "Why yes, of course." I explained that we would be giving him a lot of good medications, but that he was too old and had too much kidney disease to allow us to perform surgery. If the medications didn't work, he would die anyway, since they were his only option. If he started to die and we revived him, he would still be left with only the same medications, but he would be hooked up to machines, totally incapacitated. Was he sure he wanted that? This time he thought for a while longer. I provided a firm, reassuring nod each time he looked at me. After quite some deliberation, he finally let out a long, low sigh, and nodded his head. "OK," he said. "That's fine." He signed. I wasn't convinced that it was fine with him, but I knew it was right. The odds of him making it through resuscitation to live any kind of life thereafter was unbelievably small. Several days passed, until one afternoon my beeper called me out of a lecture. "It's Mr. Weiner," the nurse said. "He's failing." My heart sank. In the past few days I had grown to like this old man immensely. He had once worked at NASA, and was there for the original flight into space. He had been married to the same woman for 53 years. I ran up to his room in intensive care and got there to find it empty except for a nurse watching his monitor and the thin, frail man on the bed. "Mr. Weiner," I said, pulling a chair up next to his head. "How do you feel?" "I pushed 60 of lasix," to try to rid him of some of the extra fluid collecting in his lungs, the nurse reported. Mr. Weiner simply shook his head. His heart, weakened by the heart attacks, was no longer able to push the blood around his body. It had been trying to make up for it by beating faster, but the muscle had clearly tired out, and there was little else we could do. I checked the rate of his IV medication, designed to make his heart pump as forcefully as it could. It was dripping out as fast as possible. There was nothing left to do. I watched as he lay there alone, his face pale, looking even older than his 83 years. His wife was dead, and his son was on his way in. Other than the ever-slowing beep from the cardiac monitor, everything was quiet. I watched for half an hour, then an hour, as his heart gradually wore itself out. The medicine wasn't working. There was nothing I could do. He kept his eyes closed and didn't talk, saving every ounce of energy to keep his heart going. But it was a losing battle. I continued to watch, but could only think of one thing. I could push his heart for him. It would circulate the blood to his body, and give his heart muscle time to rest and recuperate. It wouldn't have to be for long, but it would give him enough time to build up more strength. I knew inside that it wouldn't matter -- his heart would just tire out again, half an hour later. It would only prolong the pain. But as I sat there and watched, saw the lines of pain slowly creeping across his face, I couldn't think of anything else I could do. I squeezed his hand, and he opened his eyes to slits. "Mr. Weiner," I said softly. "I can call a code. We can do compressions and make your heart beat for you." He didn't answer. "I know you signed the waiver, but if you tell me to do it now, we can have it going in 30 seconds." The eyes closed. I waited as the lines on his face crinkled an extra bit in thought. I wished he would hurry, before it was too late. The beeping on the monitor was getting slower. I needed an answer. "Mr. Weiner?" I asked, leaning over him, almost ready to shake him to get an answer out. He opened his eyes again, this time all the way. "Mr. Weiner?" He looked at me for a moment, and then slowly, ever so slowly, shook his head no. After another moment, he closed his eyes once more. I sat back down and held his hand. The beeping grew slower still. Then I heard a new sound, like a box whose hinges needed oil being opened. I looked, and his mouth was ajar. I leaned forward. "Thank you," he whispered, and closed his mouth once again. I watched as the lines of his face settled back into their natural pattern. Ten minutes later, he was dead. Every decision a doctor makes has the potential to be emotional. As someone with many years of training in exactly the right measures to take in each specific situation, I have worked hard to make the unemotional, "correct" decision. But as a human being who often comes to genuinely like his patients, it is easy to let my emotions take over. Although people want to be liked by their doctor, the reason they go to him, in the end, is so he can make the correct decision -- the rational one. Though only he knows, I believe that Mr. Weiner appreciated the fact that he was not surrounded by tubes and machines and yelling and frenzied activity at the end. He was glad to die peacefully. Despite the minuscule chance it would have worked, he was happy I had convinced him to become DNR. I still think about Mr. Weiner from time to time. Not because he was funny or because he was brave or because I knew him very well. I remember him when I find myself afraid to discuss some delicate issue with a patient or when I am about to do something motivated more by emotion than by rational thought. That's when a doctor or, really, anyone, I think, can start to get into trouble. salon.com | March 27, 2000   - - - - - - - - - - - - About the writer Jeff Drayer is the author of "The Cost-Effective Use of Leeches and Other Musings of a Medical School Survivor." He lives in Boston, where he is doing a dermatology residency.