Abstract
Tyler and I plodded up to Mr. Rutherford's
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room in the cardiothoracic intensive care unit (CTICU) and peered in through his sliding glass door, uncertain of what we
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would find. Mr. Rutherford's consult had rolled in at 4
Standing outside of his room, we could see Mr. Rutherford's blood, thick and molten red, pulsating through two fat hoses protruding from the right side of his neck. Woosh, wooooosssshhh went the extracorporeal membrane oxygenation (ECMO) machine, its music drifting lazily out into the hallway.
We walked into the room and greeted Mr. Rutherford, whose frail body seemed tiny, propped up with pillows, and lying sideways across his mechanical hospital bed. He was a 63-year-old African American man with a failing heart; he had been confined to the ICU for days as his team tried to stabilize him for heart transplant.
Mr. Rutherford's legs were bone thin. His feet were freezing and his belly was swollen with gas and fluid. A left ventricular assist device (LVAD) and ECMO helped his heart maintain blood flow to his organs. A soggy pillow rested under his buttocks, propping up a bed sore. There were wires, pumps, tubing, and machines everywhere. Mr. Rutherford was critically ill.
After introductions, I, a fourth-year medical student at the time, mentioned how tough it must be to be in Mr. Rutherford's position. After this empathetic gesture, I saw his clenched face soften and tears began dripping down his gaunt cheeks. His eyes locked with mine, and I saw a mixture of weariness and fear.
“This is the first time anyone is actually listening to me!” he cried out loudly. “Thank you, Jesus, Thank you JESUS! Amen, Amen, Amen!” His cry seemed to end in a quiet prayer; goosebumps erupted across my forearms and neck.
We sat at Mr. Rutherford's bedside and tried to absorb the silence. Wooosh, wooosh purred the ECMO machine. After a few moments Mr. Rutherford continued, his voice rising with passion, then breaking with the strain of what he was trying to describe. He looked Tyler, our palliative care fellow, straight in the eye: “It's torture doc, it's TORTURE, them shoving food up my nose through a tube. I'm getting close to dying you guys, and the doctor says, ‘No Walter, you cannot die, you cannot die.’”
During our conversation, it became clear that Walter knew he was no longer a heart transplant candidate and that he did not want any further life-prolonging measures. He seemed to have accepted that death was near. “How can I live with this?” he asked rhetorically, pointing to his LVAD.
His primary team had given him an incredible chance of surviving his disease. They had stabilized his heart failure and kept him alive for weeks. Unfortunately, Walter had landed in medical purgatory 2 with a life that he did not anticipate, a life that he no longer desired. “I want to die!” he declared emphatically. “I've been telling them to stop these machines for days, but no one has been listening to me! Oh God, thank you for listening!” He sank back into his bed, exhausted by the effort of speaking.
After our visit, we moved slowly from Walter's room into the hallway, feeling the gravity of his words. In medicine today, technological innovation has reached tremendous heights. Barring a massive treatment “failure,” we can keep patients from dying—or more accurately perhaps, maintain their molecules in motion—indefinitely. Yet, in the quest to preserve life at all costs, patients' voices can get lost in the humming of the machines. Wooosh. Woooooossshhh.
After talking with Walter, his nurse, and the sitter in the room who knew him from a prior hospitalization, we became certain that Walter was neither delirious nor making a rash decision. He was ready to die. Now. Walter was suffering, he was tired, and he knew it was his hour “to go home.”
I was deeply impacted by my interaction with Walter. It was full of such raw emotion. Not only did I hear the pain and agony he was experiencing, I felt it. Walter felt wronged by his medical team, as if they were treating him in a vacuum, manipulating his body instead of treating him like another human being (of note, there was documentation of intermittent episodes of delirium during his stay in the CTICU). I grieved what I had seen. Only a few months from my intern year, I prayed that I would be able to hear what my patients were trying to say in the midst of the chaos around me.
We changed Walter's code status to Do Not Attempt Resuscitation (DNAR), initiated comfort-focused care, and asked chaplaincy to speak to him about any spiritual needs. We also ensured that he spoke with his daughter, who was his healthcare power of attorney. Finally, we provided medication recommendations for when his cardiorespiratory support was eventually discontinued. The following day, Walter had a stroke code and died.
Walter Rutherford's case was the only stat palliative care consult our team received during my month long rotation. It provided new meaning for the ethical maxim of “respecting patients' wishes.” It also underscored the importance of checking in with patients regularly about their goals of care. Every physician can have a brief goals of care discussion, and as a future internal medicine resident, I recognize that a palliative care consult is not necessary to uncover these goals. Finally, going forward, I trust that when my colleagues call a stat palliative care consult, they mean it! Because, as it turns out, it's not just chest compressions that require doctors to put on their running shoes and get to the bedside as soon as possible.