My first week on call, I got called in for a code blue. This patient happened to be the sickest patient on our unit. He had a tumor on his brain stem that was affecting his vision, hearing, swallowing, and breathing, so he had received a tracheostomy and gastrostomy tube as most palliative patients in his situation do. After a series of neurosurgeries, he was undergoing chemotherapy and radiation treatments. This had all happened within the past six months, and he was determined to live. He isn’t even 40 years old, after all.
Glioblastomas are a sad diagnosis, because, despite all we can offer, neither medicine nor surgery holds a definitive cure for what surely is a fast and fatal condition. Nevertheless, this relatively young man was resolute in his decision to be full code.
So, I returned to the hospital in the middle of the night, and watched this patient endure 40 minutes of CPR. Meanwhile, as the minutes ticked away, I called his parents, who were on vacation in San Francisco because now that he was admitted to rehab, they felt they could finally relax and get away for a little bit. I called his sister, who is an surgeon in another state, who also happened to be working. I delivered the news that he was coding to her in what I hoped was a calm, collected, matter-of-fact manner, and she sounded just as scared and unsure as I felt. Miraculously, after 40 minutes of CPR, my patient stabilized, and I transferred him up to the ICU, not believing his limp body could ever be truly alive again.
And now, one month later, he has been readmitted to this unit, and I get to enjoy his Christmas decorations, his cheeky demands for only strawberry-flavored Ensures, and his analogies of straight catheterizations being too similar to unskilled billiard shots. He is the same person he was before he stopped breathing and his heart stopped working for 40 minutes, though his chest hurts a little bit from all those compressions. He is very involved with his therapy and is able to dictate his care and make his wishes known during rehab planning meetings. He is doing amazingly well for his diagnosis. And his oncologist is in full support of his optimistic prognosis.
But I worry that all of his progress may be halted at any moment by a mucous plug that results in another code blue.
When I think of all the major ethical dilemmas I’ve encountered as a resident, it usually comes down to disagreements between co-workers, co-physicians, family members, and patients. Managing different opinions among caregivers is a big part of being a physician. While physicians may have the most medical knowledge and offer understanding about treatment options and prognosis, other caregivers and the patients themselves provide insight that physicians may overlook, underestimate, or simply don’t agree with. Most of the rehabilitation team seemed uncomfortable with our patient’s full code status given the precarious location of his tumor. Perhaps some of the older physicians and nurses have seen too many patients in similar situations endure prolonged suffering and unfulfilling end-of-life care in an ICU because they would not accept the alternative of a sooner yet possibly more peaceful passing.
Still, this particular patient has reinforced a simple but important lesson. All parties involved are invested in this patient’s life. His life is their work, fueled by his continued determination to stay alive. In the scheme of the whole world, there are not that many people who care about any one individual right up until the end of their life. Though we may disagree on certain details of his care, we all commit part of our days working towards making his day as valuable and prolific as possible. There is no one right way to help a person live a full life. All we can do as care providers is offer every option and every comfort we can while maintaining respect for each others’ different opinions and ultimately respect for the patient.
Stephanie Van is a physiatry resident.
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