Of death and dying, ICU, and codes

Posted by Rachel Ng, MD (a second year Internal Medicine resident from Kaiser Permanente, San Francisco serving a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).

3/28/10

The ICU on the medical ward is located in the middle of the single long hallway, directly across from the nursing station. The ICU has 5 beds total, 3 of which have monitors. One never forgets any first deaths: during medical school, in residency, and now in Liberia.

It was my 2nd week in Liberia when my colleague and I were curbsided by the ED intern, who asked us to evaluate a septic patient. The man presented with history of several days of abdominal pain. Other than that, we knew nothing else. Altered, dyspneic, and deteriorating in front of us. Agonal breathing, apenic, pulseless. ACLS started. Crash cart. Respiratory therapist called. Epinephrine 1mg iv x1. Pulse regained! Attempted intubation…unsucessful after multiple attempts. Continued ACLS protocol…must have been almost 1 hour+ of trying to resuscitate this young man. Finally called it. The wife was asked to return to the ED. When she heard the news, became hysterical, in shock, and began wailing uncontrollably and started singing a (mourning?) song.

If the patient survives even triage in the ED and makes it to the medical ward or ICU, the chance of survival still does not increase by much. Patients are given time to declare themselves, for which way their bodies have already determined to take despite us throwing antibiotics, fluids, diretics, and other medicines at them.

Overall, ICU is a challenging place. Mainly, the patients who have survived the ICU have been DKA patients. Mainly, the bottleneck is respiratory support. Thus, septic patients, severe CHF exacerbation, flash pulmonary edema, patients hang onto life only by the skin of their teeth if they can.

The many deaths I have encountered here have been incredibly frustrating and sad. Not only do I walk into rooms on my rounds, to find patients apenic and pulseless without any prior notification, but that even if a patient suddenly crashes, there seems to be a lack of urgency to do something about it. And even if CPR is started, the lack of resources (vasopressor, ventilator in the medical ICU) truly prevent a good attempt for resuscitating patients. Two observations of this common situation to comment upon: first, it appears that patients who are younger may tend to get more attention and resuscitated earlier. Otherwise, elderly, HIV, and stroke patients (high aspiration risk) are less able to fend for themselves, with poor reserves to begin with, and thus less attended to.

Here, there is no requirement or obligation to ask about a Code Status, compared to the common practice in the US. I have heard that in the UK and in Hong Kong, it is a similar practice. Patients are not asked, “would you like to be resuscitated and to what extent…with intubation and ventilation, with pressors, etc.” In the US, I question the ethics of resuscitating a person who is with irreversible altered mental status, end stage disease, or end-stage dementia so that they can live out the rest of their days on life support and be visited upon by their family members. Here, I initially noticed my urge to start ACLS, whether it was out of habit when seeing a crashing, apenic, or pulseless patient, or else it was out of the feeling that it was the only thing I could possibly DO. Generally, I think doctors hate sitting around and not being able to DO something to help their patients. And thus for so many of my patients that I feel helpless about, due to them presenting in such advance stages of their disease or else the medicine required does not exist, ACLS became my default for actually being able to perhaps do something for them, to prevent death. Yet, as I stepped back and thought more of my patient panel…strokes with major neuro deficits, HIV encephalitis, end-stage renal disease, end-stage heart failure patients, perhaps its more than ok to let them go. For sake of quality of life and not just for management of resources. Palliative care and hospice would be an amazing addition to patient care here.