A family brought a Mrs. M to the ER on the last day of her life. They shouldn’t have.
Her home hospice nurse told them not to. Mrs. M was 80, with metastatic cancer and on palliative care, resting peacefully at home when she became feverish and confused. The nurse told her four adult children that she should stay at home and made comfortable to pass in the tranquility of home surrounded by loving family.
But her family called the new oncologist, the optimistic clinician who they sought out two weeks prior as a last-ditch effort, the doctor started Mrs. M on fourth-line radiation treatment. The oncologist coaxed the family into taking the mother to the hospital. There was still a sliver of hope!
The home hospice nurse tried to remind them that Mrs. M had been content with hospice care for months. Only with the Mrs. M’s blessing to “do what my children think is best” was she resumed on radiation therapy, already after the radical Whipple surgery, adjuvant chemotherapy, then more chemotherapy. The nurse probably shrugged in resignation. She couldn’t deny against a family’s hope.
So they came here to the hospital.
The ER hooked up Mrs. M to telemetry to monitor vital signs, drew lab tests and performed an x-ray to diagnose her with septic shock, possibly secondary to a pneumonia, definitely due to her cancer. As interventions, they started IV fluids, empirical antibiotics, pain medications, and admitted her upstairs to our medicine team. She was defaulted to Full Code.
Full Code. The “do everything” status. Full Code, where every medical intervention is invoked.
If her blood pressure drops, she would get fluids and the most powerful vasopressors. If her breathing is threatened, she would get a breathing tube. If her heart stops, she would get her ribs crushed under CPR. And if she manages to survive it, she would likely be brain damaged and never leave the hospital. Then she’d die from metastatic pancreatic cancer, probably before she’d need a feeding tube.
Kerry, the medicine intern called rushed downstairs to admit the patient. Mrs. M was okay; the IV fluids had woken her back up and she was lying comfortably, but the Kerry knew she was going to be imminently critically ill. Mrs. M said again, confidently, serenely, “do what my children think is best” before drifting off once more.
But Full Code was not the intervention Mrs. M needed. The hospice nurse knew this, trying to keep Mrs. M comfortable at home. Kerry, as an intern, knew this too. As an overworked neophyte doctor, the one who does all the nitty-gritty outlining of medical plans, who saw three of her patients die over the weekend, who’d arrived at the hospital 14 hours earlier, who understood the prognosis of Mrs. M’s pancreatic cancer, Kerry knew this. It was Mrs. M’s family who needed an intervention. Kerry sat down with the counsel of children and talked for two hours, explaining what end-of-life care in the hospital looked like. It’s not poetic heroics. It’s a violent and unnatural crucible from which a person rarely emerges intact.
I think her children understood. Before leaving for the night, Kerry entered an order for DNR/DNI, overriding Full Code. Mrs. M was moved into a private side room of the ED, quieter, darker, and removed from the chaos of the main hallways. Her children filed in, joined by a small crowd of bewildered grandchildren. Mrs. M progressed from lethargic to obtunded, but remained peacefully pain free. She could have been sleeping.
The next morning, Kerry and I visited the room to find all four children still there. Exhausted, tearful, still grappling with the weight of their decision. All night, they were tortured by the glowing telemetry screen in the corner, spending every second wondering if that would be the moment when their beloved mother would expire. They wanted no more numbers. They wanted to be present. Kerry obliged, but as she disconnected the monitor we saw that Mrs. M’s breath was beginning to falter. We slipped out of the room, and within minutes Mrs. M’s heart stuttered, stalled, then stopped. She passed in a tranquil room in the hospital surrounded by her loving family.