by: Marcia Glass, MD
I sometimes notice “DNR” on my intern’s to-do list during rounds. It usually means his resident asked why this patient, in spite of being so debilitated from his end-stage cancer, or his dementia, or his heart failure, was still full code. The patient should be made DNR instead, but doing so involves a difficult conversation with sick patients or desperate relatives, sometimes over hours, sometimes over days. Hence, the DNR on the to-do list and the knowing looks from my team. “How’s the family?” “Do they get it?” “Are they reasonable?” Any possibility of a peaceful death depends on my medical team’s ability to make people we hardly know trust us and then change their minds.
Mrs. J. was different. In her eighties, she came to our hospital in San Francisco with her favorite blanket and a book of crossword puzzles. Her husband, close to ninety, rode two buses in his neat overcoat every day to arrive promptly at 8 a.m. before our rounds started. Mrs. J. had advanced stomach cancer and knew she was dying. She had been on home hospice care and came in only to see if the surgeons could relieve her agonizing intestinal obstruction. They could not. But they did place a nasogastric drainage tube to make her more comfortable. My team adjusted her pain and nausea medications and found a hospice facility where she could be cared for until she died, instead of struggling at home. She was not fighting to stay alive; she only wanted to feel better and enjoy the limited time she knew she had left. She was eager to leave the hospital and spend her last days at the residential facility we had found for her. She had told us not to resuscitate her if she coded. She was at peace.
The one morning her husband came in late, I sat alone by her bed and asked how her night had been. We ask these questions dozens of times a week, but this encounter felt more intimate, chatty. For a moment, I enjoyed a friendly conversation, a rare pause in the day when I could sit next to someone I was caring for with no agenda. For ten minutes, no one came by to clear the breakfast tray or encourage her to sit up for physical therapy or ask her to swallow her every-four-hour pain medication. We could have been in her living room instead of under the fluorescent lights of this hospital. But then the speakers in every hallway came to life, and we heard the urgent call to a code. Code Blue. 10th Floor ICU. Code Blue. 10th Floor ICU. The announcement sounded calm, formal, aseptic. Yet the clean language belied the chaos I relive every time I hear a code: nurses shouting, doctors running, a defibrillator charging, blood everywhere. I looked at Mrs. J. and realized she seemed scared. She closed her eyes, grabbed my hand, and whispered something to herself, too softly for me to hear. These could have been words of relief that she would never go through a code, or words of compassion for the person suffering a few rooms away, or, perhaps, some doubt about her decision to pursue comfort measures only and not cling to every possible second.
I have helped many other patients and their families struggle through decisions about end-of-life care over the years since I cared for Mrs. J. As I have supported them through this grueling process, Mrs. J. sometimes comes back to my mind. I will never know what she felt when she heard someone else’s code blue, but I will always remember what I thought at the time: You made the right choice.