Saturday, August 11, 2007


Negotiating Death

Most of the time the decisions we make are straightforward…if the patient is not sick, essentially, he or she can be discharged and followed up with a primary care physician. If they are sick–they get intubated, lines, meds, etc and admitted to the ICU–easy. Today’s patient was a 48-year-old man with gastric cancer who presented to the emergency department in respiratory distress, vomiting, heart rate 140s, blood pressure 90/50 mm Hg and no advanced directives. My first instinct as an EM physician--secure the airway and start IV fluids–basic stabilization before doing anything else. I wonder why his heart rate is so fast? Why is he hypotensive? Does he have a pulmonary embolism? Is he bleeding somewhere? CT scan time? He vomits and cannot lie down. I give an antiemetic. No change. I try an nasogastric tube. It doesn’t go and he vomits again. Desat to the 70s; I pull the tube. What next? Why don’t we intubate him then we can do all of the necessary tests.

I convince the attending that this is the right plan. I realize he is a great candidate for nasotracheal intubation so I go over to another attending who is “the queen” of nasotracheal intubation and ask, “Want to nasotracheal intubate a patient with me?” “Sure,” she says. We walk over to the patient and the first thing she asks is, “Why are you going to intubate him–that is the last thing I would do.” I was confused. The attending saw my patient differently than I had–she saw an end-stage cancer patient with little chance of survival. She saw a tube going in but never coming out. She saw a family that would spend the last days with a brother, son, father, who could not speak due to this tube in his mouth--slowly drifting towards death. What are some other options?

Supportive care.

Can we drain fluid from his distended belly to allow for better lung expansion and easier breathing? Impossible–his belly was not filled with fluid, rather it was solid tumor. What about draining the fluid that accumulated in his chest? Also impossible, a needle in his thorax had a better chance for a liver biopsy than draining fluid–his anatomy was so distorted that his abdominal organs monopolized most of his thorax.

What does the patient want? I ask him. “Lets fight a little longer,” he says. What does that mean? “Do you want us to breathe for you,” I ask. “Chances are you’ll die with the tube in you.” The patient responds slowly, “just give me the oxygen and ask my family what to do.” I asked him gently if anybody ever had a conversation with him about this momentous moment—the moment you have to think hard about how you want to die. “No,” he said. I excused myself and walked to the waiting room to speak with his family. “Your brother will stop breathing in the next 12 to 24 hours,” I said. I tried to be empathetic, but clear about his options. “We can put in a breathing tube, which will probably never come out. He will be sedated and won’t be able to speak with you. Or we can let him stop breathing on his own and make him feel good while this happens. What do you think he would want? With little hesitation, his family members say in chorus, “put him on the morphine drip.”

Five sisters, a niece, and a mother make their way to my patient’s bedside to comfort him and each other.

I just negotiated the death of another human being.

Am I trained for this? Can anyone be “trained” for this moment? Can we predict the end of life? Should we? What if I had insisted upon an intubation? Would this have changed the patient’s outcome? How would it have affected the life of the entire family?

My patient walked into the hospital a little short of breath thinking he suffered from a bad cold. He was hoping for a little relief--maybe some antibiotics and fluids. Instead he had to decide if this would be the last day of his life. He was only 48. He died at the end of my shift.

How does it feel to make such an incredible decision? How did my patient and his family make the decision so quickly? What could I have done better? How can I ever understand what that moment feels like to the patient?

"PostScript" is a column designed to post moving, comedic, or interesting stories from anybody who works in or is a part of the health professions. All comments are welcomed.

Please feel free to share your story. To have your story posted, please send it by email to


SeaSpray said...

Great Blog!

I hope you don't mind that I blog rolled you. Can't wait to come back to read more.

the anonymous therapist said...

Those sudden, unexpected end-of-life decisions are always very difficult, especially if you can see the pluses and minuses of both sides of the issue. Very well-spoken post.

Anonymous said...

In his shoes, what would you want done? Would you like to not speak to your family during your final 12 hours? Would you want your training done to you? Just asking.

Thanks for posting this, it's very good food for thought.

Adam said...

Thanks for the comments - this was truly a learning experience. The patient died just as my shift ended.

Christian Sinclair, MD said...

Excellent post. Thanks for allowing us to hear your inner voice.

I think most people do not appreciate how much physicians are contemplating even when it comes to a decision that may seem instinctual or easy to those on the 'outside.'

As a palliative medicine doctor, I get to see residents and medical students see something different about hospice and palliative care when they see it in comparison to our classic disease oriented medical model of illness. But I always have to remind them that they have to learn first how to be very aggressive before they can use wisdom and experience to guide them on when it is OK to not use the technology at their disposal. This involves the softer (but still critical) skills of medicine: communication, ethical contemplation, compassion, empathy.

Your questions at the end are very natural and I am glad to hear you have thought about the implications about the power these decisions can have. But if they are made in a team approach with the patient's goals and values in mind, it can be noble, and honorable.

I would encourage you to find a palliative medicine doctor in your institution and touch base with him/her about working on how to talk to families in the ER about death and dying, because this will not be the last time something like this happens. Our ER consults the palliative care team fairly often.

Check out Pallimed
for some good palliative care info or this Powerpoint on palliative care in the ER.

Adam said...

Thank you Dr Sinclair for your thoughtful comments. You've put together a wonderful site on palliative care as well.