Did you hear that?
Most of my time taking care of patients is spent in the intensive care unit, which is really just one snap judgment after another. It was in the ICU that I met a guy I’ll call Mr. Jones, and his amazing family. I can’t recall his real name at the moment, and it would be illegal for me to tell you what it was, anyway.
Mr. Jones had been diagnosed with advanced lung cancer just a few short weeks before I met him. I couldn’t imagine that this came as a surprise to his family. He had smoked dozens of cigarettes every day for many years, and over the last few months he had gone from skinny but relatively healthy to emaciated. His color was awful, sallow and almost grey. His hair was lank and obviously had been falling out, not from chemotherapy but simply from not eating enough to keep up with the calorie demands of the voracious tumor that had spread through his body. Worst of all, the cancer wasn’t just in his lungs. It had spread to his brain, the highest of high-rent districts in the body, and he had what we in medicine would call “a huge goombah” in the back part of his brain.
If this sounds bad, it was, but even this wasn’t enough to land him in the ICU. No, he’d been admitted to the hospital for what looked like a pneumonia, and he was getting worse. The plan had been to try to get him over his infection and help him get some nutrition and some strength back, and then the neurosurgeons would consider opening his skull and trying to cut out the part of his brain that had been eaten by the cancer. As he got worse and was moved to the ICU, though, this plan was put on hold.
Shortly after arriving in the ICU, it became clear that we would need to put a breathing tube in Mr. Jones’s throat and put him on a mechanical ventilator to maintain a safe level of oxygen in his blood. This is a major deal, full-on artificial life support. For me, it’s standard practice to discuss the pros and cons of such a maneuver with a patient or his or her family, particularly when that person has an incurable condition – say, lung cancer that’s spread to the brain – or is likely to die fairly soon. It was under these circumstances that I met Mr. Jones’s family – his wife, his daughter, his son-in-law, his grandson, a big chunk of the Jones clan. I explained that he was getting worse, and that we were at the point where we’d be needing to put a breathing tube in, and had he ever talked about his wishes about ventilators or CPR or any of that. Despite being folks of modest means and even more modest education, the Joneses were canny in the way that so many folks from the rural South are – they had livin’ smarts. They understood that my question was code for, “He’s probably going to die, and since he already had an incurable cancer, you might want to think about not putting him through all of that.” They were pissed! His wife got right up in my face, looking as thin and haggard as he did and reeking of cigarettes, and explained that her husband was a fighter, a proud VETERAN, and that he was not going to roll over and give up. She growled her thoughts about the incompetence of the neurosurgeons through clenched teeth, and why hadn’t they operated WEEKS AGO.
“Ma’am, I’m sure they didn’t want to do anything that might hurt hi….”
“WHAT DO YOU CALL THIS? AIN’T HE BEEN HURT NOW?!”
I asked if she understood what his disease meant, if anyone had explained it to her. Big mistake. She explained that she wasn’t stupid, that yes she knew exactly what was going on, and that no, we weren’t going to talk no more about what we would or wouldn’t do. I was to do everything possible to save her husband’s life, no matter what. “He can’t die.” So I went into his room, said a silent apology to him, and gave him the drugs to put him to sleep so that I could put a breathing tube in him and hook up the ventilator. It was only a few hours after that that we were once again in his room, draping him to create a sterile field so that we could put a very large tube in his jugular vein to give medicines to fight his infection and to keep his blood pressure up in a range compatible with life. He was in shock and getting worse by the hour.
Things stabilized a bit. He settled out, and his family settled in. Over the next couple of days, I got to know them and I got to know him. They were exhausted and heartbroken. The cancer HAD been a surprise to them. Of course it had. No one goes around thinking their loved one has a terminal disease. They struggled with the unfairness and the indignity of it, as so many people do. Why had he gotten so bad so fast? Why hadn’t the neurosurgeons operated on him? Mr. Jones had been a tough-as-nails soldier in Vietnam, but he also made jewelry. A cross he had made hung from the ventilator on a beaded chain he had strung himself. His son had followed in his footsteps and was currently stationed in Iraq. He knew his dad was sick, and the paperwork for emergency leave had been filled out, but who knows with the military?
It was 4 o’clock in the morning on his third day in the ICU. My pager went off. Mr. Jones’s heart rate had precipitously dropped, then rocketed up, then swung back down. His blood pressure had plummeted. Worst of all, he was no longer triggering breaths on the ventilator. It was doing all of the work for him, his vital functions now completely supported by machines. A scan of his head confirmed the worst. He had bled into his brain, into the middle of the tumor. The pressure inside his head was immense, and no surgeon on earth could save him. He was, for all intents and purposes, brain dead. When his family arrived that morning, they saw the stricken look on my face right away. Poker has never been my game. I explained what had happened, and that there was nothing to fix this. I explained that we really needed to think about stopping the aggressive life support, because we were only prolonging his death. His wife came apart, and explained that their son had been granted approval for emergency medical leave and would be coming Stateside soon, but that because he was coming from an active warzone, they could not be told when exactly he was leaving or would arrive.
I struggled not to weep right along with them, and we came up with a plan. Keep the ventilator going. Stop all the other medications. No CPR, no heroics. When God wanted him, God would take him, and none of us would do anything to stand in the way. Even as my heart ached along with the Joneses, the medical science part of my brain knew that we were probably talking hours, a day at most. He would have a cardiac arrest, or his blood pressure would drop and he would just… shut down. Medical science is pretty good, and his blood pressure did drop, to a level that is incompatible with life (50/30, for those of you out there who are curious). But he didn’t shut down. His heart rate stayed steady. The ventilator chugged away, chuffing 14 times a minute no matter what. He continued to pee, despite the fact that there was no conceivable way his kidneys were getting any bloodflow at all. Still, no movement, no cough, no twitch, no nothing otherwise.
This went on for two days. I just knew he was going to stop at any moment, except he didn’t. His family asked questions that I tried to answer, though with less and less certainty every day. We were off the map here. Then, Mrs. Jones’s cellphone rang. Her son was at the airport and would be making his way to the hospital shortly. This was great and awful news. His father was still alive, but we all knew that not long after this young man arrived and told his father good-bye, we would be stopping the ventilator, and he would be gone in minutes.
But that’s not what happened. As I was anxiously awaiting the son’s arrival, preparing to meet this young man whose family I had already grown very close to and under these incredible circumstances, my pager beeped to life. A patient was in the emergency room in shock and needed to come to the ICU right away. I gave the go-ahead to bring him on up, and he arrived within minutes. The team got to work immediately… just as Mr. Jones’s son arrived. I shook his hand briefly, apologized profusely for having to rush off, and turned him over to his mother. “Well, at least they’ll have a little more time together while I work on this other guy,” I thought. Wrong again. I can only relate the facts of what happened next as they were told to me. The son walked into his father’s room. He leaned down and said, “It’s okay, Dad. I’m here.” Within 90 seconds, Mr. Jones’s heart rate slowed to nothing, then stopped. Even before the nurse peeked her head into the new patient’s room to whisper to me that Mr. Jones was gone, I knew. Somehow, this brain dead man had waited for his son, had heard that it was okay even when he shouldn’t have been able to hear anything, and then he left.
The Jones family came back several weeks later, to thank everyone for everything. There were hugs and tears and promises that they would all take care of each other. I remembered how angry and hurt they all had been, and marveled still at the healing that had already taken place. I can’t explain Mr. Jones’s death with science. It simply wasn’t a scientific thing. But I know what I saw, and I know that Mr. Jones’s snap judgment taught me more about the art of medicine and about the magic of everyday life than any textbook or lecture or scientific journal ever will.