CMO

Comfort measures only. What does it mean? Peel away all treatment, antibiotics, oxygen, IV fluids, tube feedings…start the morphine gtt and let nature take its course, right here in the hospital. Is this the kind of death I would want? I guess it depends on the alternatives. I can only wish that my patients could be in a better place near the end – at home, with the people they love. I only wish that I could give them something more here, play a role beyond doctor, bearer of sad news. Perhaps the hospital chaplains feel more fulfilled. I try very hard not to abandon or ignore these patients and there families, but I have a sense that the comfortable, familiar role which I have learned to fill is no longer of any use to them. I feel as though I need to play another role, but I am not quite sure what it is. Be by their side, comfort them, guide them as I did before. More than anything, I want to give them answers, certainty, a plan. But I cannot.

Death rates in medical ICUs vary from 8 to 20 percent, and are much higher when you consider how many patients die soon after they leave. The world of critical care is a world of those who are actively dying, young and old, from a variety of illnesses which we are not able to make better. COPD, congestive heart failure, cancer – so many diseases spiral out of control towards the end, and as medical professionals we are at a loss as to how to prevent this from happening. There are so many things we still do not fully understand, and so many things we do not know even how to begin to treat. This is the world of medical mystery – and of human mystery. We can hope for a miracle, or a peaceful passing, but beyond that we are reduced to mere human beings, standing beside our patients and their families, watching them suffer, unable to relieve all the intricate layers of pain and grief which lie beneath the surface.

Difficult Conversations

Today was a day of conversations. Discussing the end-of-life is always difficult. We owe it to our patients and their families, of course – we owe them an objective opinion which will serve best the interests of the patient. But where do we draw the line between doing too much and doing too little? As much as I don’t believe that invasive, painful treatments which detract from and make unpleasant the dying process are things we should be doing, I also have difficulty giving up hope, and letting go of my desire to fix people. After all, that is what I have been trained to do. But medicine does not have all the answers, and neither do I.

Families look to us for direction and guidance in their time of greatest need. It is our duty, as compassionate physicians, to provide them with this in as objective a manner as possible. It is also our duty, as compassionate physicians, not to fall apart. And I haven’t – until I leave the hospital. That is when the feeling of regret and failure wash over me, as I mull over these families and their loved ones who, despite my years of hard work and training, I am not able to make better.

What makes all of this more challenging is that people close to me have recently resurfaced in my life, both as family members of the sick and as the sick themselves. This hits close to home. I watch families struggle in the ICU every day, but I keep far out of my mind the possibility that my family could ever be there. Denial is the straightforward explanation. But the river runs deeper than that – the more I know, the less I want the human side of me to be present in the hospital. The more I know, the more I want to protect myself. It is the most basic of survival mechanisms in a world where people die every day. It begs the question: what is my purpose here? I know that my role is not to put in lines, to prescribe medications, to play doctor; I have a larger role than that, but I haven’t figured out how it all fits together yet.

Letting go of patients is hard, but it is harder when I think of it as letting go of somebody’s mother, daughter, sister, brother. It is much easier when I think of it as letting go of a patient. Either way, the moment of truth – walking into the room to declare someone dead – is not something I’ve gotten used to. It is a solemn moment, when all eyes are upon you. And there your stethoscope is, resting right on the skin above her heart, as you wait the long 60 seconds to declare her dead. You are the last one to touch her from the medical community as alive, as a patient – and you are the first one to touch her as a corpse. You are the bridge between worlds, but only in a minuscule, concrete way which makes you feel simultaneously bigger and smaller than life itself. It is a moment when everyone watches, waits, as you listen. It is a moment in an unwelcome spotlight. A moment of finality, but also a moment of uncertainty. For where do we go after this? And is there a soul? We are not trained for these kinds of thoughts, so the long 60 seconds come to an end, and we walk away, on to the next duty of the day.