Dying the Natural Way

“What was the creatinine again?” the Critical care fellow asked, as I had rushed through the labs section of my presentation. In the time that I spent looking down at my notes to find the creatinine value, and reporting it, the fellow and I found ourselves alone at the patient’s door. We looked around to find that the remaining 6 members of our ICU team had ran over to the room next door. That room had become home to Mr. K for the past 2 weeks. His prognosis was dire. In fact, I remember my first introduction to Mr. K’s case being the following conversation:

“If he codes, we must keep it a very short code. We do not want him to suffer.”

There we were, at Mr. K’s door, looking up at a bradycardic rhythm. His heart was beating ever so slowly, at 30 beats per minute, irregularly, arrythmically. “Normally” we would call a code, fill his room up with nurses, physicians, staff, with a line of folks waiting to press on his chest and plea for his heart to beat rhythmically. But this was no normal occurrence. During Mr. K’s ICU admission, multiple attendings spoke with his wife about his wishes, as he was unable to make his own decisions. The complexity of a family member deciding if their loved one should undergo an attempted resuscitation, is in itself cause for another piece. For Mr. K, the conversations and understanding of his family’s position had evolved over the 2 weeks. At this point in time, while we stood in his room, the attending physician had been entrusted by Mr. K’s wife, to decide to not attempt to resuscitate him, if she deemed that the feeble body of Mr. K would not benefit from it.

“We are not running a code. Please give Fentanyl.” Our attending said, decisively, and to our relief. You see, seeing patients critically ill, with no realistic hope of return to a life with quality, we (as in, the collective healthcare profession) become partial to a certain acceptable way out of this world. Our human-ness comes out. We think, “Would I want that for me” and more appropriately yet “Should one want that for them”. The group of us standing in Mr. K’s room with him, watching him in his last minute of life, wanted this for him- the peaceful exit. We had seen the alternative on most days- the chaotic, loud, bloody, messy scene of a code. We cared about Mr. K, and were fortunate to have 2 weeks leading up to this moment to clarify what we should do in this moment. With most patients, we, and they, are not so fortunate. Most people do not like to think about their last moments.

Though we wanted Mr. K to have a peaceful exit, standing there, watching him die, was eerie. This was supposed to feel natural… yet it felt wrong. It seemed that the natural way to die, the default if you will, has been replaced in our minds as what happens most frequently in hospitals and on the media. The loud beep and the flat line, with the rush of white coats and scrubs who attempt, and many times, fail to bring the body back from the dead. That has become our default. My fellow medical student later reflected on this shared moment of Mr. K’s death that a reason she chose anesthesiology as her field is because while a patient is in the operating room, they are always “full code” meaning they will undergo attempted resuscitation. Standing by, not actively doing anything, while a person dies, was too difficult for my friend. Of course, I do not blame her.

Through it all, I gained the utmost respect for the ICU attendings who had the foresight to speak with Mr. K’s family, patiently, calmly, and slowly break down the misconception barriers of the role that attempted resuscitation did or did not have for Mr. K. I hope to emulate them, not allowing my career-born bias creep into my discussions with patients and families, but also tirelessly and patiently providing them the facts needed to make the decision of how their loved one may leave.

–Hedieh Matinrad, MS4