I doubted that Mr. D would leave the hospital alive. A 60-year-old man from western Massachusetts, he was chronically ill and suffered from heart disease, diabetes, cirrhosis and kidney failure. Now, after being admitted to the hospital two weeks ago to undergo an elective surgical procedure, his postoperative course had been complicated by a major heart attack and wound infections. We met in the intensive care unit, where he was transferred for respiratory distress.
As the nurses wheeled him in on a stretcher, I surveyed his debilitated body and immediately noticed that his respirations appeared to be growing shallower. Hustling to his bedside, I performed a rapid blood test that confirmed his lungs were struggling to rid his body of poisonous carbon dioxide, and we intubated him emergently. As I glanced up at a monitor and watched his blood pressure trickle ominously downward, I picked up the telephone to let his family know that he was critically ill and they should probably come to the hospital.
The next morning, as we rounded on Mr. D, our team’s conversation turned to his code status. “He’s full code. We’ll have to address this,” one person remarked, and members of the team nodded in agreement. The unsaid was that we felt he would be unlikely to benefit from CPR and that a DNR, or “do not resuscitate” status, would be more clinically appropriate.
According to Julie Knopp, associate director of palliative care services at Beth Israel Deaconess Medical Center, “one of the challenges in discussing code status is that the discussion often starts with ‘code status’ when it should start with a discussion of the patients’ understanding of their illness, their goals of care, and their values about end-of-life decisions. While we, as doctors and nurses, can comment on the medical perspective of an illness and form an opinion in this capacity, only the patient, or those empowered to speak on his or her behalf, can judge how to value this information.”
As we embarked on this important conversation with Mr. D’s family, we spoke candidly and compassionately about the graveness of his condition. He was critically ill, with dangerously low blood pressure, respiratory problems and a serious infection. These medical insults were challenging enough for a healthy patient to endure, but in a patient with Mr. D’s chronic illnesses, the prognosis was especially poor. Moreover, we felt that he was unlikely to benefit from CPR if he were to have a cardiac arrest, since we were already providing near-maximum support for his circulatory and respiratory systems. They were clearly in shock, oscillating between tears and bewilderment, but Mr. D’s brother managed to assemble a response on his family’s behalf: “Matt’s a fighter,” he said. “Let’s not change anything for now.”
A few days later, Mr. D’s respiratory status improved moderately and we were able to extubate him. Though encouraging, he was still critically ill, and his blood pressure and respiratory status remained tenuous. Seizing the opportunity to involve him in the important conversation about his goals of care, we assembled his family at his bedside and again discussed his clinical picture. He was clearly distraught, sometimes unwilling to participate in the conversation, but when he finally mustered a comment, he talked about wanting to see his grandchildren again, along with other unfinished plans he had for his life. “I want to have a shot if I need it,” he said, referring to CPR or re-intubation.
My team revisited the issue with Mr. D and his family on several other occasions over the next few days, but he eventually needed to be intubated again for respiratory failure. Over the course of these discussions, our team’s position became increasingly at odds with the wishes he expressed, and the tone of the conversations changed. But Mr. D held his ground.
Mr. D was still in the ICU when I left, though I later learned he was eventually discharged to a rehabilitation center. I called him to talk about his experience during that tumultuous hospitalization. “It was definitely a stressful couple months,” he recounted, but he was happy to be at rehab and looked forward to eventually returning home. On his conversations with physicians about his code status and goals of care, he was blunt: “I needed people around me that were more supportive of my goals and what I wanted to do. The doctors didn’t have the same kind of optimism that I have. They practice medicine, but they don’t know everything. Sometimes they are right, and sometimes they are wrong.”
We were wrong about his prognosis, but physicians welcome when patients do better than expected. Our position meant, however, that from the patient’s perspective, we were not supportive in all the important ways.
“When I’m at the hospital next, I’ll look you up,” he said.
“Please do, I’d love to see you,” I told him, and we hung up the phone.
Joseph Ladapo, HMS ’08, is a resident in internal medicine at Beth Israel Deaconess Medical Center.
The names used in this column are pseudonyms, and the opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
