One Round

Ms. A was a woman in her early 50s with metastatic pancreatic cancer. Despite a Whipple procedure (a Hail Mary in itself), her cancer had been steadily progressing and her health status was reciprocally declining. Late on a weekend evening, Ms. A was confused and subsequently fell at home. Her son brought his mother to the hospital, not totally understanding the severity of her overall condition.

Ms. A was quickly admitted. The residents on the medicine team easily saw that her condition was grave. Ms. A would likely die within a few days, at the most. They consulted palliative care.

When the palliative care team entered the room they found Ms. A conscious but drowsy and surrounded by her son and a number of her sisters. The team told her she was dying and recommended that she sign a DNR. CPR would be futile, they said, only leading to further pain and suffering. Ms. A, they explained, would be better served by comfort measures than by aggressive interventions. The physicians and nurses present for that conversation did not know to what extent Ms. A understood what they had just told her. However, with multiple family members firmly entrenched at her bedside, Ms. A spoke what turned out to be her last wish. “I want one round,” she muttered, and then drifted into unconsciousness. She would never become lucid again.

In the days that followed that first encounter, we, the palliative care team, had numerous conversations with Ms. A's family. We still believed that resuscitative measures would be inappropriate. Ms. A's sisters and her son stood by her words. “She wanted one round,” they repeated. “We want her to have one round.” Again and again, the team explained why they believed that CPR and a “full code” would do more harm than good. Again and again, they were met with the same response: “One round.”

Eventually the two medical teams called a full family meeting with Ethics. The room was filled with tension. Once more the physicians explained Ms. A's limited prognosis to her family. This time, it seemed that they internalized what it all meant, and her son collapsed onto the floor, shaking and crying. He now understood his mother was dying. It became clear that, despite what had previously been a tough exterior, he was a young man desperately afraid of losing his mother.

After multiple family members calmed Ms. A's son down, the team revisited the topic of code status. Ms. A's sister promptly cut them off. “We told you we want her to get the one round she asked for. One round.” The ethics consultant now attempted to explain that “one round” made little sense to the medical team charged with executing the resuscitative efforts. Was “one round” thirty chest compressions and two breaths, or five cycles of this with subsequent defibrillation? Did they expect medications to be used? Was Ms. A to be intubated? Clearly, no one expected the family to be fully able to answer such questions, and the ethics consultant and the medical team sought to convey to Ms. A's family the notion that their request involved considerable ambiguity. The family, especially Ms. A's son, remained steadfast, and began to grow increasingly angry. They were obviously tired of these discussions and felt as though the physicians were badgering them. The conversation was at an impasse.

Rather than abandon the search for a compromise, the ethics consultant asked if they understood why Ms. A might have desired one and only one round of resuscitation. Ms. A's sister responded without hesitation. “She wanted one round because she hoped, at the moment before her death, God would save her.”

Over the course of the next day we had many discussions amongst ourselves about what the right course of action would be. Strong opinions and emotions flew through the room. The attending physician found it ridiculous that the hospital did not have a so-called “unilateral DNR” policy that would allow the physicians to change the patient's code status without the surrogate decision maker's consent. For her, it was a disservice to the patients at our hospital that physicians were bound to accept what seemed to her to be an irrational family's demand. The palliative care fellow was moved to tears by the chest compressions, injections, and electric shocks that a code would entail. She would not be complicit in causing Ms. A undue harm.

Quietly, I pondered Ms. A's request. For Ms. A, God and her physicians would work hand-in-hand to deliver her from the evil of her terminal cancer. In other words, she sought salvation. Was this not just a religious reframing of the gospel of modern medicine that we had been preaching for almost a century? Or did Ms. A's hope point to something deeper, beyond the physical? Perhaps Ms. A was asking us to shift our focus from our fear of cracked ribs and punctured lungs to that which lay beneath. As physicians we are most comfortable treating and protecting the body. Ms. A, it seemed, looked to us to protect her soul. Was this as unreasonable as we had initially assumed?

After numerous discussions with Ms. A's family and all of the physicians, nurses, and managers involved in her care, the ethics consultant forged a solution acceptable to everyone. When the time came, Ms. A would receive one round of CPR, including the necessary medications. She would not be intubated.

Ms. A's heart stopped a few days after that last family meeting, late in the afternoon but before the incandescent glow of the hospital fully replaced the sunlight. The residents began their CPR as they would have for any other patient. The chest compressions were strong and regular; the breaths delivered through the bag-valve-mask were rhythmic and deep. The young doctors at Ms. A's bedside were going to give God the opportunity to save her. Ms. A's sister, the one who so vehemently protected her dying sister's voice, told the residents to stop after only a few seconds. She could not bear to watch them continue. The senior resident pronounced Ms. A dead.

Ms. A's final wishes were respected and she received her one round. God and the doctors may not have saved Ms. A's life as she had hoped, but those of us involved in her care all seemed at peace. Perhaps, I reflected, Ms. A's family was the most reasonable of all of us. From the outset until the very end, they protected her, both body and soul. As I begin my career in medicine, I hope I can learn to do the same for my patients.