take two

 He was fighting a losing battle against cancer and was receiving experimental chemotherapy.   His spouse demanded everything be done to keep him alive.  “He’s too young to die, we have small children,” she sobbed. I suggested making him DNAR, do not attempt to resuscitate, and she became angry. 

“Boston  tells us the chemotherapy might work, and if you make him a no-code, you have extinguished any hope we might have.”

The Hospital called.  He was failing. He was on pressors, intravenous medicines used to maintain blood pressure at times of crisis.

“I’ll come right down, “ I said. I would speak to the spouse, discuss the perils of being a patient with advanced cancer who underwent cardiopulmonary resuscitation.

By the time I arrived at the intensive care unit, he was gone. He lay on a gurney, eyelids open,  eyes bulging from their sockets from the 30 minute-long  attempt to retrieve him.  His expression was one of abject terror.

His arms were swollen and bleeding, stigmata from multiple attempts to insert 18 gauge needles as he lay dying. I beheld a scene of un imaginable violence.  

  My patients with advanced disease who undergo in-house  CPR share  a common fate. They all die alone, without family in attendance.  When CPR begins, the family is hustled out, useless civilians driven from a battlefield, an alien arena in which they are useless.Worse, their weeping and attempts to comfort their loved ones makes resuscitation hazardous for patient and family members alike.  One cannot  embrace a loved one receiving  a 360 joule electro conversion shock. 

                     I am wary of buildings bearing messages, Work Makes One Free, Ignorance is Strength, but the portal to every Medical school and hospital should bear the warning:

  Death is not the enemy, Suffering is.

Modern medicine has forgotten this simple truth, at our own peril.

             I have taken to making house calls.  Some patients are bed bound, so I throw my stethoscope in the Honda, don a white lab coat and drive Connecticut streets, seeking my wayward patients.

            The results have been startling.

            I enter a house. The patient lies in the living room, in a hospital bed, dying.

In our storied past, loved ones died of old age.  Once upon a time, we died at home.   We died upstairs in the master bedroom, covered in a hand -made quilt as family members said goodbye, reminisced, shared the vigil against encroaching night.

Nowadays, no one dies of old age.  The term itself has become vaguely grotesque, politically incorrect, and pessimistic. Patients die of atypical tuberculosis, protein wasting syndrome and immunodeficiencies, By giving name to these conditions, we imply that treatment, and hence salvation, exists.

 I blame Dylan Thomas.  We have taken his admonition to rage against the dying of the light to heart

Family members approach me. “ What did Boston tell you?”   Boston, medical Mecca, has become shorthand for,   "the place where my loved one will receive a lifesaving diagnosis and treatment.”

           

I blame ourselves as medical providers. We sometimes encourage futile therapy, claiming to restore hope but forgetting that  the new proposed therapy has the  slimmest chance of success, at the  expense of additional suffering for patient and family.

Insurance companies’ policy rates are skyrocketing.  I am not excusing their behavior but rates increase when we decide as a culture that a brain MRI or 30 minutes of a cardiopulmonary code would be more therapeutic than soft classic music in an upstairs bedroom where the lights are low and the air smells of lavender lotion. 

To be fair, we are staring to recognize that a patients’ death is not necessarily an indication of our failure.. We now use the phrase: Do not Attempt to resuscitate, rather than Do Not Resuscitate.   This subtle shift suggests there is no magical procedure to return our loved one from the banks of the River Styx.    We need to teach our medical students that every patient will eventually die, will eventually fail to respond to  any number of  expensive treatments and uncomfortable testing.

This raises the point: Is Cardiopulmonary Resuscitation ever useful, especially for  patients with cancer?

The answer lies in a patients’ health prior to  CPR.  If an otherwise healthy patient with cancer ( or without cancer, for that matter)  suffers  a cardiac arrest,  CPR offers a reasonable chance the patient will leave the hospital alive. For debilitated cancer patients (defined as those who spend at least 50% of the day in bed) a 2002  study pronounced   Hospital based CPR “ Futile.”

       I have been fighting  Chronic  Lymphocytic leukemia since 2007, and underwent  a stem cell transplant in 2011.   I wrote of my disease and the need for universal vaccinations in a 2011  New York Times op ed piece. I wrote that cancer taught me the value of community.  Cancer has now taught me that death is not the enemy, suffering is. I am in remission ( excuse me, Ptoo ptoo) but suffer  daily from Graft verses Host disease, an insidious  syndrome in which my donor cells attack my own innocent tissue.  I have experienced days so  pain filled that I  wished I could end my suffering in any way possible.  I don’t mind dying, I dread suffering, especially without a reasonable expectation my misery will end.  I view CPR for the terminally ill as a form of needless misery.

       My patients are becoming more involved in their healthcare. They demand that I review their CT scans and blood work with them.  I see real irony here, but I also see a chance for improving health care delivery. My patients panic when their MCHC  (mean corpuscular hemoglobin concentration) is elevated. They want to know what that means, The honest answer is  “if you are not anemic,  an isolated abnormal MCHC doesn’t mean much.”   I wish they showed as much interest in their DNAR status. We ask our patients to sign DNAR papers which describes CPR in the mildest terms .  Our form reads, in part

        if you stop breathing would you allow a tube to be       inserted into your throat?

       These forms should be more honest and more accurate. They should read:

       The chance of survival  in any patient with any terminal disease who undergoes an insertion of a breathing tube and  the application of electrical shock to the chest is essentially zero. During this attempt at resuscitation, you may experience pain, anxiety and fear. If you require the insertion of a breathing tube, your family will be forced to leave the room and there is a possibly you will die in pain and without loved ones around.

       I contemplated requiring  all patients requesting “ full code status, no matter what” to watch a video  of a patient undergoing  CPR, but that would be too gruesome  to watch.  Viewing such a video could produce its own suffering.

        If I were hospitalized because my cancer had returned, I am certain I would request DNAR status .

       A Johns Hopkins study found 90% of all graduates from the Johns Hopkins school of Medicine would decline CPR unless they had an acute, treatable condition. We  physicians have  run or watched  too many attempts at cardiovascular  resuscitation  to want this procedure performed on us.

        When my time comes, I want to die in my bed,  the sound track of  Kiss me Kate  playing in the background, a generous dose of morphine and Ativan  soothing my central nervous system and the  healing scent of chicken soup wafting up from the kitchen. Wouldn't you?