Thursday, August 10, 2006

Struggling with the Dead

We already have a huge patient census (9 ICU patients!), which is miserable enough on its own. But who would have thought that out of all our patients, it's our brain dead patients that cause the most trouble. You would think these two patients -- these two motionless bodies that, for all intents and purposes, are dead -- would be the easiest to take care of. But no.

As each patient has family that will not accept the fact that these patients' brains are technically dead (perfusion studies have shown that their brains are not receiving blood flow), they refuse to allow us to perform a "terminal extubation" ... meaning they won't let us disconnect the ventilator from the patient so that the patient may die.

At first we thought we could invoke California state law, which mandates that once a patient is declared brain dead, terminal extubation must be performed within 12 hours. Unfortunately we couldn't take advantage of that law because we could not just yet declare them brain dead. And what was the reason for that? Because a patient cannot be declared brain dead until all of their electrolyte abnormalities are normalized.

So ... in an effort to declare these patients brain dead, we are busy correcting their low sodium, elevated blood sugars, and elevated creatinine. Which means we are giving our dead patients saline, insulin, and (get this) dialysis. Even better, one of them has an anemia, so he is about to be transfused with some red cells.

I don't want to come off as insensitive, since I know this must be a hard situation for any family, but there comes a point when evidence makes it clear the patient will never recover. I guess it's easy for me to think like this, since it isn't my loved one that is affected.

In any case, it's quite a hassle taking care of our dead patients.

(With all that said, I hope someone from above doesn't strike down upon me with great vengeance and furious anger.)


Anonymous said...

Perhaps it is not vengeance and anger that you should fear. Instead you should fear that as a 'doctor-to-be', you demonstrate a penchant for egocentricity and an astounding lack of empathy.
Remembering for a moment that you are a medical student, you see the situation as a "hassle" for you. What sort of hassles do you think the family are experiencing ? This is not just a "hard situation" for them. It is a catastrophic event which will change their lives forever.
Developing some humility and empathy may allow you to see that as a student you are privileged to be learning by being involved in the care of any patients, regardless of the status of their brain.

DrivingMissMolly said...

As a person who had to come home from a cruise to take her Mom off life support, I want to say that I do not find your post offensive. It is simply a reflection of your experience. Here is mine:

My Mom was not quite brain dead, but we knew there was no hope and we knew she would not want to be kept "alive" like she was. She had a massive brain bleed.

What I would like to see is training or empathy for the family who choses and is ready to terminate life support. The people in ICU acted like they had never dealt with a brain dead PT before. They were horrible. They told us only one person could be in there after they disconnected her. We stayed anyway. They let the monitors blare away after she was removed from the vent. The people who came in to unplug her acted ashamed as they skulked about doing their thing. Death is part of life, people!

They never even mentioned organ donation until my sister remembered my mother's wishes and brought it up.

I am proud to say that she went back to an administrator after Mom was buried and complained. I hope it did some good.

I wish she could have died in hospice like my mother in law. Those people knew how to deal with death and treated us wonderfully.

Some people may need time to come to terms with the inevitable. I know my mother in law refused to terminate care for her husband because she felt it would be murder. Maybe it is generational, maybe a religious thing. Some people actually said that they thought my Mom could recover with prayer! This made it even harder for us. We know. You don't suddenly get a new brain for the one that is dead.

Anyway, that's it.


On the Same Page said...

I believe the comment of anonymous is a gross over-simplification. I see medicine as an evidence-based science, and that includes the deduction and determination of fact. It is the reason we consult physicians, specifically for their objectivity in determining fact. The continued administration of medical "interventions" in a patient with the evidence of these profusion studies is absurd. To acknowledge this fact is hardly egocentric or lacking in empathy.

Likewise, it begs the definition of the provision of "care" in hopeless situations. Does merely maintaing body systems while a family comes to terms with a catastrophic event constitute "care?" Does it constitute reasonable care? Is this how we understand palliative care? And for how long does a physician maintain "care" in a hopeless situation before s/he is no longer considered egocentric or lacking in empathy, but simply stating the obvious? And for how long should a physician maintain the feelings of "privilige" in administering "interventions" that are, in fact, futile.

These are an astoundingly complex issues, factually & emotionally, and scolding a student for attempting to process them is shortsighted.