Talk First,Act Later

Mrs. S's blood pressure dropped suddenly. She breathed fast, as if she had been running. I arrived at her bedside short of breath myself, summoned stat by the ICU nurse. Two days earlier we anticipated this moment would come. We'd seen the large blood clot in her heart on echocardiogram: a time bomb. Flapping precariously, the clot threatened to break free and wedge itself into a major blood vessel in the lungs. It was a recipe for sudden cardiac death, with a little respiratory failure thrown in. The blood thinners we'd prescribed were unlikely to dissolve such a large clot, especially given the bad humors in her blood from her cancer. The respiratory therapist popped his head into the room. “Want to intubate her, doc?”

Putting a tube into a gasping person's airway is like scratching an itch for an ICU physician. It's what we do. We're trained for it and more—to drag life back from the precipice using all the expensive paraphernalia of intensive care. Trouble breathing? I can put a tube in a lung within seconds. I can ventilate the patient with a bag and mask at 12 breaths per minute. Flagging blood pressure? Pressor medications will tighten up your vessels and pump up the pressure. Our feet are forever on the starting blocks, waiting like a sprinter for the gun to go off. Every second counts for the 40-year-old otherwise healthy woman with a serious pneumonia or the 28-year-old man hit by a bus. But Mrs. S was a different and a much more common story. Spinal metastases had continued to grow despite multiple trials of chemotherapy. Strong opiates didn't stop the gnawing pain punctuated by startling knifelike jabs as the hungry cancer digested healthy bone. Connecting her to a ventilator would just buy time. But for what? Forced to lie still on her breaking back, tape steadying the breathing tube snaking its way into her lungs through her mouth, she'd be tied to the bed, alone, probably until her death. And so it was with great relief that I knew the answer to the respiratory therapist's question. “No, we won't be intubating her. Let's give her a dose of the morphine and see how she feels.”

Earlier, on the day of the echocardiogram, I had met with the patient and her family at the bedside to deliver the bad news. We had reached the end of the line for treatments for her cancer. The chemotherapy wasn't working, the cancer continued to worsen. Now there were other life-threatening complications. The clot was enormous; when it broke off, it would cause either respiratory distress or a cardiac arrest. Intubation and cardiopulmonary resuscitation were options, but they all agreed that there would be no benefit, only a prolongation of dying. Mrs. S and her family processed the limitations and risks and decided that attempted resuscitation efforts would not be in her best interest.

The respiratory therapist nodded. “Good decision, doc.” In the spirit of my specialty, I gave her extremely aggressive care. I monitored her respiratory rate and distress constantly for the first hour and treated her with medications to relieve her shortness of breath. Once she was stable, I changed the room from one that had focused on machines, catheters, and alarms into one that provided a peaceful, calm haven for this woman at the end of her life. A fan blew air gently on her face. Music played on the radio, which her family had brought in days before. Her daughter sat in a chair next to the bed, her head on her mother's lap, holding her hand. The patient died peacefully two days later.