I was a medical scribe in the ICU when I met Mr. C. He was an 83-year-old male. He came to my physician’s care with an abscess at his tracheostomy site. At the time, he was deconditioned from a long hospital stay complicated by recurrent infections. Along with a history of Myasthenia Gravis, he suffered from severe atherosclerosis. With limited perfusion to organs, one particular organ began to lose function promptly: his gut. Malabsorption further worsened his condition, making wound healing difficult. By the time IV nutrition was started, our team knew we were fighting a losing battle. As he continued to lose subcutaneous fat, more wounds opened and made him further immunocompromised. He eventually developed sepsis once the bacteria entered his bloodstream. As a result, there was a drop in his blood pressure and heart rate. Sepsis protocol began as IV fluids were started, and he was placed on vasopressors to maintain his blood pressure. However, the kidneys had taken a major hit. His electrolytes needed to be replaced, and as his blood became increasingly acidotic, he was eventually placed on continuous bicarbonate. The liver was the next organ that began failing. Soon, he needed blood transfusions from the bleeds from his GI tract, extremities, and nose.
In addition to this physiological battle, Mr. C was also fighting an emotional one. His daughter was a devout Catholic and refused to place her father on comfort care measures despite physician’s recommendations to admit defeat. Our team watched, day by day, as Mr. C crashed and was revived, only to crash again. A few hours before her father’s death, Mr. C’s daughter finally decided to change Mr. C’s code status to comfort care. Our team was able to start a Morphine drip and stopped other interventions, allowing him to pass away as peacefully and painlessly as possible the next morning. After coming to the hospital over the last few weeks, always checking on him first to make sure he was still with us, I was overcome with a peculiar loss when I found him gone.
What is the duty of the clinician in this case? I had never experienced an instance where family and religious dynamics conflicted with a medical professional’s advice prior to this event. Mr. C’s situation was both daunting and eye-opening. I was able to witness his physician find the balance in two ways. First, he advocated for his patient by providing him with the best interventions we had and concurrently continued to apprise Mr. C’s daughter of her father’s condition, allowing her to make the best decision. Second, he translated the medical jargon to simple words that were appropriate and educational for Mr. C’s daughter. For example, when a rapid response code was called, he explained to Mr. C’s daughter, “Your father’s heart momentarily stopped but he is stable now, and on medication to keep his rate stable.” He thoroughly explained each diagnosis and informed her that it was impossible for someone in Mr. C’s state to recover. Daily, he held her hand through the ordeal and guided her to make the ultimate decision to place her father on comfort care, as this was the most merciful option for our patient.
Mr. C’s story serves as a reminder to me that the clinician’s role is to always do right by the patient. The physician I scribed for did so by being perceptive and tactful with patients and their families as they went through an incredibly tumultuous time in their lives, including the death of a loved one. The experience elucidated what a crucial difference such a clinician can make: they may assist patients with terminal illnesses with confronting their realities, as well as help the family members of the patient understand their choices.