Ms. A was brought in from a nursing facility by the transport team my first week of ICU rotation. I had no idea what I was doing and my first thought was, “she looks old, I hope she doesn’t code before someone else gets here.” She was around 95 years old and had the kind of problem list that gets summarized as “complex medical history:” COPD, chronic kidney disease, diabetes, some kind of lymphoma status post treatment that had returned. Now she was here for one of the usual chief complaints that bring people her age into the ICU: COPD exacerbation, MI of some kind, strokes–in this case it was septic shock secondary to a urinary tract infection.
This isn’t one of those educational cases where the diagnosis and treatment required the clever differential puzzle-solving that draws a lot of people into internal medicine. Everything was more or less straightforward for the team: treat with antibiotics, manage fluid balance, oxygen, blood glucose. My main challenge was reciting all of the items of my presentation in the correct order as I fumbled through my first week of ICU, and the first time I had routinely dealt with treating adults in about a year. This also isn’t one of those situations where I formed a strong emotional bond with the patient and learned a valuable lesson about how we’re all afraid of something. Mrs. A came in with a mental status that was better assessed with the Glasgow Coma Scale instead of the Mini-Mental State Exam. My most meaningful interactions involved getting her to open her eyes or squeeze my hand. Even her family was scarce, a single daughter who arrived from who knows where and sat quietly in the room, nodding wordlessly as we updated her with the daily plan. She didn’t have many questions; she’d been through all of this before.
A few days into her care, Mrs. A’s condition began to deteriorate. She started requiring pressors, increasing oxygen requirements, decreasing renal function. It was time to have “the talk” with the daughter, which in the ICU means discussing the patient’s code status. With the cancer coming back on top of everything else, the daughter decided it was time to change Mrs. A’s code status to DNR/DNI, comfort care only. We put in the consult to hospice and stopped the antibiotics, but she couldn’t fully transfer to their service until we weaned the pressors, so she stayed put. Daughter was still there at bedside, quiet, not asking for anything. There were no other family members, no decorations or flowers or balloons.
I came in the next morning to pre-round on my patients, nothing had changed except that Daughter had left to go take a shower for the first time in days. I went about my business and was asking one of the interns a question when the person monitoring tele called out, “hey, room x just died.” This wasn’t new; I’d had patients die before, I’d been with sick loved ones and attended funerals, but this was the first time I was actually present when it happened. The intern got up to go call the time of death: Mrs. A wasn’t even his patient, but he was the closest. “Have you seen a death called before?” I shook my head no.
He started showing me the death exam: verifying lack of cranial nerve responses, listening for a heartbeat. I listened, heard nothing, and thought about how many other times over the course of medical school I had listened to obviously living people and also heard nothing. Maybe I expected this silence to be different, somehow? Suddenly, she breathed, and the monitor beeped once as a blip ran through the horizontal green line. I must have looked surprised because the intern started explaining “agonal respiration.” I knew that was a thing, I saw air was only going out and not in, but it still startled me. I thought that the actual moment of dying would be more, well, final. Everything stopping all at once, like a light switch. This was more like watching a wind-up toy run out, where every so often it ekes out a couple more turns on its way to the end. It was mechanical, much like the dissections in anatomy lab I did what seems like forever ago.
Since then a lot of my patients have died after a changed code status. For these people, I suppose ICU is limbo, a kind of loading screen for death. Though death inevitably comes for all of us, here it is acutely on its way–maybe in days, maybe in hours. We’re all just waiting to find out when.