The overhead speakers announce, “Attention please, attention please. Code blue, Ellison 16.”
As soon as I hear those first two words, I drop everything and make my way to the nearest stairwell to run the few flights up to the general medical floor where the code blue is taking place. When I arrive, the patient is nonresponsive, and a bag-valve mask is being used to deliver oxygen. The medical senior (the senior medical resident charged with leading all the codes in the hospital) is in the room at the foot of the bed assessing the situation. Each of the other residents who has responded, along with nurses, pharmacists, respiratory therapists, are doing different jobs.
One junior resident, the on-call resident in the Cardiac ICU, has his hand in the patient’s groin. He’s in charge of making sure the patient has a pulse. One intern goes to pull up the patient’s most recent labs on the computer. Another resident pulls the patient’s green chart (the one with all the vitals and the medication record) and the gray chart (with the daily notes) and is doing a quick scan. A medical student who has been on call on the floor gives a brief history of the patient to the medical senior. Several interns are waiting in the wings to begin chest compressions should this be necessary.
The medical senior pauses and begins to summarize the situation so that all present are on the same page. In very complicated, tenuous codes, there will often be several times when we pause to review the situation and assimilate the incoming data.
“We have a 60-year-old male with lung cancer, metastatic to the brain, found unresponsive and hypoxic. He has a pulse; we have good oxygenation. Prognosis is weeks to live. He is currently ‘full code.’” This means either the patient or his healthcare proxy has expressed the desire for aggressive medical management, including intubation if necessary.
I get on the phone to call the patient’s wife. It’s 3:45 a.m., and I call her, a complete stranger, to inform her of her husband’s precipitous decline. I introduce myself and apologize for calling so late. I recount the events that have just unfolded. I tell her that we do not know exactly why this happened. Then I ask her if her husband would want to be intubated and put on a ventilator.
I am very specific: he is having difficulty breathing. “Would he want to have a tube put down his throat and be placed on a machine that would breathe for him?” She tells me she is not sure anymore. She sounds confused and frightened. I ask her if she could call her daughter and come in to the hospital. I write down her cell phone number and tell her I will call her with any updates and that in the interim, we will consider him full code.
This is not the kind of conversation meant for 3:45 a.m. between strangers. Unfortunately, this is when they often do happen—when the issue is forced by a change in clinical status. I am always very specific in my description of what intubation will entail to make sure that patients and their proxies are fully informed.
I page the covering oncologist, who describes the conversations that have begun to take place between the family and the care team regarding code status. Palliative care has been involved, and the plan is for a consideration of hospice, but the family has not reached that point yet.
Only about half of patients with metastatic lung cancer have discussed hospice within four to seven months of diagnosis, according to a recent study in the Archives of Internal Medicine (by Haiden Huskamp, John Ayanian, and colleagues in the HMS Department of Health Care Policy). This study also found that about 28 percent of patients who wanted to discuss do-not-resuscitate (DNR) status with their oncologist did not have an opportunity to do so. Further, only a third of patients who had discussed DNR status also discussed hospice care. There are many barriers to discussions of hospice in patients who are terminally ill, both on the part of physicians and of patients.
The oncologist agrees with the team’s assessment that intubation is futile, and he says he will call the patient’s wife and then come to the hospital to discuss the situation in person.
In the hours that follow, the family, speaking for the patient who is not responsive, makes decisions for him. They decide not to escalate care and, in fact, to pursue hospice care.
Often, I have observed making the decision not to intervene is one of the hardest decisions to make. With all the advanced technology and machines we have in place to extend life, choosing instead to let nature take its course seems anathema.
Erica Seiguer Shenoy, MD–PhD ’07, is a resident in internal medicine at Massachusetts General Hospital.
