Life Cycles

My most recent call night was exhausting. It wasn't the lack of sleep because we actually got to rest for four hours. It wasn't an onslaught of new admissions because we only got 2 early in the evening. Both were straight forward gastrointestinal bleeds. It was exhausting because 3 of our 12 patients died within eight hours of each other.

The first was a man in his 40s who came in severely septic with an unknown infection that triggered his diabetes and put him into a diabetic coma. By the time he reached us, he already had major brain injury and had even lost some of his reflexes, the brain's most primitive function. The prognosis was clear. The family was consulted and after a few days agreed to remove the breathing tube and the medicines holding his blood pressure up. As the interventions were withdrawn, nearly 20 relatives crowded into his room crying, moaning, and wailing. I could hear them even down the next hallway and the sound of their voices was harrowing. We sat outside his room and watched the telemetry on the screen, observing his heart beat slow, change rhythms, and ultimately flatline.

The second patient was my own, a 75 year old lady who had been battling metastatic pancreatic cancer for nearly 3 years. She was admitted for a blood stream infection which we had successfully treated, but the infection tipped her cancer over the edge. I watched each day as first her liver failed, then her lungs, then her kidneys. I met with her family early on and with the help of the palliative care team, explained to them that there was nothing left to treat, that her body was letting go. They told us they had family coming from out of town to say goodbye and wanted everything done until then to keep her living. So we kept her on the ventilator and we kept the norepinephrine dripping to keep her blood pressure up. I crossed my fingers over the next 3 days that her heart wouldn't give out because there was no amount of CPR that would resuscitate a woman that ill and to attempt to do so would be a traumatic way to die.

The family came on Friday. By this time her liver was so dysfunctional that her belly and lungs had filled with fluid. She had stopped urinating. She was completely unresponsive to voice or even pain. She was still breathing, but at a much faster rate than the machine was set for. She was going to tire out very soon.

The palliative care team was unavailable, so I met with the family myself. I told them the story of her cancer, why she came to the hospital and how we had treated her. I explained that there was no surgery and no medication that could cure her and that her body was already letting go.

They asked, "So what are you telling us, doc? What should we do?"

I tried my best to be direct. "Her body is letting go. It's dying and our machines are just keeping her longer. At this point, I would suggest removing the medicines and the breathing tube so that her body can let go peacefully."

It was an obvious solution and the best option for a feisty woman who had already beaten the odds of her cancer. Her family was tearful, but in agreement. As this was my first time leading a withdrawal-of-care conversation, it was a relief to have a unanimous decision. I signed the orders to remove all the supports and 3 hours later, she passed. As the physician, I had to walk into her room and listen to her heart and lungs. Silence. I flashed a light in front of her eyes. No response from the pupils.

"Time of death, 1832."

And then there was paperwork.

Then a CPR code came over the loud-speaker and we ran to find our third patient dying. He was a man in his 50s with lymphoma, admitted for an as-of-yet undiagnosed abdominal infection. After a round of CPR, he regained his pulse, but he was getting IV infusions of norepinephrine, vasopressin, and dopamine just to keep his heart and blood pressure working. The family crowded into the room, still wanting everything done for him. So we kept the medications dripping and again watched as his heart beat slowed on the screen. Because of the IVs, for 30 minutes, it wound flatline and then pop back up again. Then when we were sure, my co-intern walked into his room and pronounced him. Again, the family's crying was painful to hear.

I felt like I needed a drink. So, I did the next best thing a pregnant woman at work could do: bought myself some peanut M&Ms. I ate the whole bag at once.

Then before I could sit down, I had to go upstairs and see a Mrs. H., 55 year old woman with bacterial meningitis who had lost peripheral IV access. I placed a central venous catheter in her internal jugular vein. Then I got called back downstairs because Mr. T, a 47 year old man with AIDS and PCP pneumonia, wasn't breathing well on his ventilator.

And so the night went...


All these deaths in the same day had me thinking a lot about the cycle of life. How could I ignore it when I'm walking around, carrying a new, growing human life? When I was giving the patient chest compressions and feeling my baby kick at the same time, I felt just overwhelmed by life force. It is a beautiful and completely mysterious thing.

I can imagine that when Champ is growing up I'll tell him, "When you were just a tiny baby in my belly, I was running around the hospital taking care of very sick people and getting very little sleep in tiny sterile call-rooms. And when patients got very, very ill and died, you kept me sane because you reminded me everyday that there is rebirth and hope, that there is a cycle to life that is both natural and peaceful."

What Sarah Said by Death Cab for Cutie

And it came to me then that every plan
Is a tiny prayer to father time
As I stared at my shoes in the ICU
That reeked of piss and 409
And I rationed my breaths as I said to myself
That I’ve already taken too much today
As each descending peak on the LCD
Took you a little farther away from me
Away from me

Amongst the vending machines and year-old magazines
In a place where we only say goodbye
It stung like a violent wind that our memories depend
On a faulty camera in our minds
And I knew that you were a truth I would rather lose
Than to have never lain beside at all
And I looked around at all the eyes on the ground
As the TV entertained itself

‘Cause there’s no comfort in the waiting room
Just nervous pacers bracing for bad news
And then the nurse comes ‘round and everyone lift their heads
But I’m thinking of what Sarah said
That love is watching someone die

So who’s gonna watch you die? So whos gonna watch you die