It is probably best to go gently into that good night.

About 9 days ago my grandfather passed away in Bangalore, India at the age of 86. He lived a world away from me, and unfortunately I am unable to travel to India to be a part of the funeral process; the thought of going to India and taking leave of absence from residency never even crossed my mind. My dad flew over last week to help with arrangements and will be there through Dec. 22nd. Around the same time my grandfather passed away, I was consulted by the surgical & cardiac intensive care unit teams to comment on prognosis in critically ill, comatose patients.

The first patient was an African American woman in her 60s who went into cardiac arrest during a surgical procedure to remove an adrenal mass which is thought to be cancer. She was essentially normal prior to the operation. She received norepinepherine and pressors and CPR in the operating room and had return of circulation within approximately 4 minutes. The surgery was aborted. She remained unresponsive for 2 weeks on a breathing machine. She developed renal failure and was placed on continuous dialysis. She developed hepatic failure for unclear reasons. An MRI of her brain was obtained which showed multiple small to medium sized strokes; possibly related to her low blood pressure intraoperatively, possibly embolic from her heart. During a transesophageal echocardiogram, she briefly had cardiac arrest again and CPR was started with return of circulation.  I was consulted for assistance with assessing prognosis. Her sedating medications were stopped 12 hours before I examined the patient, but she remained completely unresponsive.

My thoughts were that the prognosis was not good. She had a possible adrenal malignancy, renal failure, hepatic failure, some strokes, and was nonresponsive. Although her pupils react to light, the fact that she had no purposeful motor response or movements of her limbs after 2 weeks made me feel her likelihood of making a meaningful recovery was poor. I based this off a landmark paper entitled Predicting Outcomes in Hypoxic Ischemic Coma written by David Levy in the 1980s. Over 200 patients who were comatose after cardiac arrest were retrospectively examined, and their prognosis was charted based on their neurologic function at certain points in time. Almost none of the patients who had absent motor response to painful stimuli had a meaningful recovery.

The next day I discussed the case with my supervising attending physician. She had a very different opinion. The patient had been on high doses of sedating medications for 2 weeks and in the setting of renal & hepatic failure, her opinion was that these sedatives could linger in the system indefinitely in spite of dialysis. The strokes were not devastating and the patient had good function of her brain stem reflexes. Her opinion was that we were unable to comment on prognosis because we needed more time to see how the patient would do after the sedatives had been discontinued.

I was frustrated. I felt there was evidence in the literature that the patient should do poorly. Multiple organ systems were failing in this patient, and I felt that the family should know that the likelihood of making a meaningful recovery is low. I felt the best possible outcome would be withdrawing care and letting this patient pass. Fundamentally, I felt it is wrong to have a patient with no meaningful neurologic function use expensive ICU resources and take up an ICU bed that could go to someone who needs lifesaving interventions in a more acute setting. I shuddered to think of the family holding on to hope and have this patient remain unresponsive indefinitely for months, years, in a long term care facility where she would be getting dialysis and fed through a tube.  Although I was unhappy, I held my tongue.

The next day at the family meeting, the ICU team, surgeons, myself, and a very large African American family was there. I echoed the opinion of my attending physician that I cannot comment on prognosis at this time since the patient was getting heavy amounts of sedation and it would take longer for her to clear these medications because of her renal and hepatic impairment. However, I said that if there is no improvement in the next few days, I suspect the prognosis would be poor based on my experiences and review of the literature. I qualified this with the statement that every patient is unique and I could not make any guarantees that I knew whether this patient would get better or not.

The patient's husband was asked what would his wife want in a situation like this where she is unable to tell us herself.  He said confidently, "she would want to live." This made me sad. Perhaps if my language had been more devastating and aggressive, the decision would have been made to withdraw these invasive life prolonging methods which I felt were futile.

3 days later, I received a page from the surgical intern that the patient was improving. I re-examined the patient, and she was spontaneously opening her eyes. She was wiggling her toes on command. And that was it. She was not moving her arms or her legs otherwise. She had a tracheostomy in place but could not move her mouth or talk.  I'm not sure how I feel about this. A large part of me hopes that my initial evaluation is wrong and that this poor woman will walk out of the hospital someday. If she has managed to survive 2 codes and cheat death twice, she is fighting for her life. A smaller and more guilty part of me hopes that she suffers some debilitating blow such as septic shock or disseminated cellulitis and passes away before she gets transferred to a long term care hospital where she remains minimally responsive indefinitely.

The day before my grandfather died, I was consulted to assess for brain death and comment on prognosis in a gentleman in his 50s who underwent therapeutic hypothermia after suffering cardiac arrest.  This patient was also normal previously with his only medical comorbidity being hypertension. While at work, he developed some chest pain, and then lost consciousness. EMS performed CPR and took him to an outside hospital. The patient was intubated and connected to the breathing machine, and the code continued for about 2 hours with continuous CPR. Eventually, the pulse was regained and there was return of circulation. At some point, the decision was made to start therapeutic hypothermia to slow down his metabolic demands and theoretically improve his chances of survival. A head CT was obtained and showed diffuse edema/swelling throughout his brain along with possible downward herniation of the cerebellum through the foramen magnum with brainstem compression. The next day I was called to comment on prognosis.

I knew that the prognosis was bad. The patient was comatose, his pupils were nonreactive to light, and he had no brainstem reflexes. When patients meet criteria for brain death, then the hospital has the prerogative to withdraw life prolonging measures to end life. However, this gentleman did not meet brain death criteria because the department policy is that 72 hours have to pass after a patient is warmed from therapeutic hypothermia before a brain death evaluation can be performed.

I communicated to the family that the patient's head CT looked bad and key structures in the brain appear to be compressed. I discussed that it is hard for me to comment on prognosis since the patient was "ICED" the day before. For this reason, I could not declare him brain dead. His daughter was a nurse. She asked my many questions about the details of his medical care. I was intentionally vague. I discussed that it may be reasonable to wait the full 72 hour period to see if any recovery was made, although I was pessimistic that this would happen. His daughter seemed well educated and had a keen grasp of how things work in a hospital. His wife said she would pray for a miracle. 3 days later, the patient remained unresponsive, and the family gave permission to take him off the breathing machine and allow him to pass.

Going back in time about 8 days prior to the day after Thanksgiving, my family and I were discussing my grandfather A.N Murthy. He was around 86 years old. He lived by himself in his home in India. He owned a car which he very reluctantly agreed to stop driving just 1-2 years prior; the traffic in Bangalore is overflowing and can be unforgiving. He hired a cook who would make his food. His neighbors looked out for him. I saw him last in August. We went for a long walk with my dad near the high school I went to.  At that time, he seemed quite healthy, and I was impressed. When I said goodbye to him to go back to Chapel Hill and continue residency, he encouraged me to visit him. He told me he could feel himself grow weak, and he wished me the best of luck with my career.

The day after Thanksgiving, my family was reminiscing about my grandfather's visit. My mom expressed concerns that he may be too old to make the long trip from Bangalore to Cincinnati by himself. If he were to get seriously ill in Ohio, it would be very complicated arranging his care.

I was engulfed in the neverending work hours of residency. I told my mom that I deal with death on a regular basis. I said that people live longer these days, and in spite of living long full lives, patients and their families actually wish they could have lived longer well into their 80s, 90s, and beyond. I said that at his advanced age, things are unpredictable. My exact words were, "he may live to 100, or he may die tomorrow, both are equally possible." It was very easy for me to maintain this aloof assessment. It was clear that I would never be responsible for caring for my grandfather if he were critically ill. Unfortunately, he passed just 1 week later after I made this nonspecific prognostic declaration.

On an early December morning, he told a family member that he felt weak and ill. He was taken to a nearby hospital in Bangalore, and was intubated and connected to a breathing machine. I do not know anything else about the nature of his illness. The next day, a doctor decided that the prognosis was poor and he was extubated and let go. There was no family meeting, there was no "goals of care discussion."

I miss my grandfather very much and I feel like a part of my has been taken away that I will never get back. But I am glad that there was not a "family meeting" or "goals of care discussion." His close family was scattered many miles away throughout India and America. Making arrangements to have discussions on the phone would have been incredibly difficult to account for the different time zones. I doubt that our family could quickly and efficiently come to a decision about whether to prolong his life. My gut feeling is that if he somehow lived through whatever it was that made him sick by means of invasive life prolonging therapies, he would wish he were dead.

So why do American physicians have to ask for the permission of family members designated as health care power of attorneys to withdraw life prolonging therapies and let patients pass? Should doctors have supreme authority to withdraw life prolonging therapies? If this were the case, maybe we would become corrupt and hospitals would be where you go to die rather than where you go to get better. It's much easier to let patients go than to keep them alive indefinitely. I think Americans have an unjustifiable fear of death, and that our medical system needs to re-evaluate the way we handle end of life care. I'm glad that this topic is being discussed more and that physicians are rethinking end of life care.