Circumventing Death
"Seemingly obvious, the best way to avoid death is by keeping people alive...”
Circumventing Death
Throughout my four years of medical school education and training, my only encounter with death was the one time I backed away and cried in the hallway. Even after that reprimand, no discussion followed. No lectures ever mentioned the possibility of death, let alone the frequency with which a physician can expect to encounter it. Nor were the varied ways a person can die, how to recognize when a person is dying or how to care for a person as they die scripted into any medical curricula. This never struck me as odd because the whole point of the hospital, I believed, was to help people avoid dying. In fact, the only aspect of death formally addressed is when preparing to start the first year of residency.
The telltale sound of a code announcing a person is on the verge of dying is quickly recognizable and unique to the hospital. My heart, like Pavlov’s dogs, became trained to race every time the overhead intercom system blared “code blue.” I learned it means a stampede of medical residents is about to rush to a dying person's aid. But I didn’t realize that I was buying into the incorrect perception that the only way a person dies in a hospital is if they fail to survive a code. Therefore, it made perfect sense that until I was a part of the resident code team, I would have no reason to see a person die.
The education, culture and practice of medicine explicitly and implicitly instill three ways to circumvent death: avoid it, avert it or ignore it. And if you have to be near it, be as formal and unemotional as possible.
Seemingly obvious, the best way to avoid death is by keeping people alive, or at least trying to, for as long as technology allows. ACLS is beyond the chest-thumping and mouth-to-mouth the Red Cross taught me before I was allowed to volunteer as a lifeguard my sophomore year of high school. ACLS involves memorizing complex algorithms based on electrical rhythms of the heart that dictate the use of certain medications and, yes, the "clear" machine. Formally known as an electric cardioverter, this device charges a set of paddles with a specified number of joules that are then applied to the naked chest of a person to electrify their heart back into what is called normal sinus rhythm. It is important that anyone not wanting to be electrified “clear” themselves from the field. Hence the need to yell “clear” before the paddles send their electrical pulse. And while some movie depictions of this device in action are correct, dramatizing the abrupt jolting of a person back into a state of painful alertness, most movies represent its use incorrectly. Electric cardioversion is never employed when a person's heart is “flatlining.” If the monitor has no squiggly line, unlike what Hollywood depicts, the paddles are of no use.
Passing the ACLS course is more than necessary. It is a distinguishing line in the sand. It's what makes it possible to finally behave the way doctors are uniquely portrayed: heroes capable of bringing a person on the brink of death back to life. In contrast, medical schools are not required to provide any standardized hospice- or palliative care education. As a result, it remains the exception and not the norm that physicians-in-training are taught how to intentionally care for a person as they die.
Odds are high that every resident will be responsible for “running” a code at some point during their training. The first doctor to arrive at the bedside after hearing the announcement becomes the person in charge of making all the medical decisions: what tests to order, what procedures to perform, what medications to administer, to use or not to use the “clear” machine, and when to call it. Meaning, when none of the interventions seem to be restoring the person to life, it is up to the code leader to also declare the person dead. ACLS training outlines what should trigger a person to first "call” a code (as in initiate the stampede) when a person is found unconscious, without a pulse and/or not breathing. The algorithm then flows down several paths based on what is happening with the patient's heart. Interestingly, death, also known as "calling a code" (as in call it off), is not part of the ACLS sequence. Instead, the diagram loops back on itself indefinitely. Death avoided.
Unlike what so many movies and television programs would like viewers to believe, if a person survives a code, they are not ready to go out on a date with Dr. McDreamie moments after being revived with the clear machine. Serious illness takes a toll. If we survive, we don't return to what we previously related to as “normal.” A new normal must be created. Averting death is what happens when we talk about everything that medical science can continue to do with confidence and compassion without regard to the physical, emotional, financial and spiritual costs. Preserving hope of survival, meaning a return to a life that resembles the one before a serious illness sets in, is the implicit training embedded in medicine. We always have one more treatment we can offer. Whether it will restore health is not part of the conversation. The aversion to talking about death is unspoken and universally assumed, and the euphemisms healthcare providers speak, "It might have an effect.... Some people show a response.... We can't be 100% certain, but we can try ...," are how we reinforce and train our patients and families to remain averse to talking about death. We incorrectly believe that to say otherwise will destroy trust, hope and faith in the care we are providing. Patients and families don’t want to hear it, and doctors don't want to say it, so we skip it. Until we can't.
Declaring a person dead is both a procedure and a requirement before a body can be released for burial. When in the hospital, this “pronouncement” is under the purview of a physician.
My moment to learn the intricacies of “pronouncement” is prompted by a page from a nurse.
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I am in the resident room having dinner with my senior resident, Austin, and fellow interns on call for the night. Half of the windowless resident sanctum is filled with a well-loved wooden table. Various chairs flank its sides. Two bruised couches line the walls. They act as makeshift storage bins with a plethora of supplies residents habitually need in the middle of the night. Dressings and bandages of all shapes, sizes and materials are methodically as well as playfully strewn across the couch cushions. If you aren't careful, you might inadvertently sit on a suture needle left in place from a late-night stitching tutorial. The other two walls are covered by bookcases filled with tomes on the various medical specialties. The smaller anteroom contains desks with banks of phones and computers.
I leave my personal pan pizza to move to a wall phone.
A nameless voice answers, "Dr. Gross?" after a single ring. "Ms. Nelson has died. No family is present. I need you to come pronounce her."
I have never met this patient or her family. I am covering for another intern who had informed me his patient, Karen Nelson, was CMO—Comfort Measures Only. That meant it was expected she was going to die soon.
"What's up?" Austin asks as I come back to close the lid on my pizza.
"I need to go pronounce a patient."
Austin hands me a small notecard with a checklist.
"Follow my instructions," he begins before pausing to take a gulp of coffee. He points to the first line on the card: Fixed pupils. "First, look in their eyes with a penlight and see if their pupils react."
I nod and put my hand to my now-long white coat chest pocket to make sure I have my penlight on me. Moving down the list, Austin continues to point with one hand while holding his coffee cup in his other.
Absence of breathing. Absence of heart sounds.
"Use your stethoscope to listen for breath sounds and a heartbeat. Listen for longer than you think. Supposedly three minutes, but I don't usually check my watch."
Absence of pulse. Absence of reflexes.
"Finally, feel for a pulse and say their name really loudly while doing a sternal rub."
Austin sees my eyes go wide.
"Use your knuckles to rub hard on their chest." Austin does a bit of a pantomime on his chest. Seeing my discomfort, he adds, "Or you can squeeze their fingernail to see if you get a response." He takes my hand, gives me a nod as a way of asking permission, puts down his coffee and presses hard on the nail of my index finger with the side of a pen.
"Owww!" I squeal as he rolls his pen over my nail.
"Don't worry," he says as he puts his pen back in his breast pocket and slurps from his coffee. "The nurses have already done all this stuff. It's just a formality so you can declare the time of death which you need for the death certificate. Then come get me because the hardest part is filling out the death certificate."
What Austin told me was mostly true. Before they page, nurses already know a person has died. And under certain circumstances—namely when a person dies of "old age"—it can be shockingly difficult to complete a death certificate. Old age is not recognized as a cause of death by coroners.
What Austin and the notecard failed to mention is what actually is the most difficult part of pronouncing a person dead: communicating with their family. As scary as it sounds to discuss the possibility of death upfront with patients and families entering the hospital, being caught completely unaware only makes things a bazillion times worse.
****
I met Ms. Lillian Lyon ten minutes before she died. She had just been transferred to our intensive care unit from another hospital with a rapid onset of a blood infection, called sepsis, after undergoing a minor surgical procedure earlier in the day. When she arrives with her family, all are in wonderful spirits. Even Lillian is talking and smiling. At first blush, anyone would wonder why this seemingly vibrant person needs to be in a place reserved for the sickest of patients. Technically, I understand that the medications that Lillian is receiving to keep her blood pressure stable require that she be monitored in the ICU. But that's not what I say to her family.
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