The man with the fedora in the ICU

I visit him in the ICU day in and day out. It’s the man with the fedora. I see him every day because he is not going anywhere. The metastatic cancer has ravaged his colon, bones, liver, and lungs. His oncologist is willing to try more chemo — but not now — maybe someday “when he is stronger.” The man has already failed several other regimens. The oncologist hasn’t seen him in a while. He’ll see the patient in clinic when he is discharged. He thanks us for keeping him updated.

Every day as I log on to the electronic health record in the top left corner, I see the man’s picture. Taken at an outpatient visit many months ago, he is smiling and wearing a charming brown fedora with a feather. It’s tilted just so and not by accident. He’s unrecognizable from the man in the bed. The smile is full of optimism. The twinkle in his eye. He took time to pick out the fedora that morning, perhaps with advice from his wife of fifty-plus years. He has several on his hat rack in his bedroom, but this was the right one that day. He wanted to look handsome for the doctor. He was pleased they took his picture that day. He sure looked suave in that fedora.

Now the man with the fedora has pneumonia, sepsis, DVT and C. diff infection. He has aspirated, has a trach, a feeding tube, a PICC and an IJ line. The nurses gently turn him, preventing pressure ulcers. Dressings are changed with care. His catheter bag is emptied, ins and outs recorded. An ever-rotating list of antibiotics, pressors, electrolyte replacement; an ever-growing list of doctors. Critical care, nephrology, infectious disease. neurology. Surgery (“not a candidate”). A drug rash prompts a dermatology consult. Cardiology sees him for EKG changes. All of us have seen him now — an endless list of consultants rotating through the case. “This unfortunate man, well-known to our service …” Medical students, residents, fellows, attendings, NPs, PAs, PT, OT, RT, pharmacy, case managers, social workers, chaplains, dietary. “Will sign off.” “Will discuss with attending.” “Thank you for this interesting consult, call with questions.” We speak to him with kindness, although he is sedated and unresponsive. “How are you today?” He never answers.

His family sits dutifully by his bedside, day in, day out. Each of us gives an update on our organ. “His kidney function is looking worse today, and he will need to start dialysis.” “We’re changing the antibiotic.” “He needs an angiogram, but we’ll wait until he’s stronger.” The palliative care team sees him regularly, discussing goals of care. There are family meetings. All the teams congregate and update them. We hear, “He’s not ready to give up yet.” “Dad was a fighter!” “100 days in the ICU! He always was stubborn.”

Every day, we all log on to the electronic health record and see his picture — the picture of the handsome man with the fedora. We write our notes, cut and paste, copy forward. The notes grow longer, a running journal of each day. “No acute events overnight.” “No changes.” With a smart phrase, I pull in the labs and vital signs.

I sit there and write my daily note. Check a vancomycin trough. The candida in the urinary catheter does not need treatment. Continue contact isolation. Call with questions. As I write, the man in the fedora stares back at me from the computer screen. “Can’t you make me like this man again?” he seems to ask, challenging me. But he will never be that man again.

What does the man in the fedora want us to do for him? Is this what he saw for himself? When he picked out that fedora, that suave brown fedora with the feather, did he know that just a few months later, he’d be slowly wasting away in an ICU, kept alive by an endless parade of doctors?

One day, I enter the ICU to find the man in the fedora was not in his bed, a sparkling clean empty room betraying no hint of what had occurred in the night. But the electronic health record didn’t mince words: “You are entering the medical record of a deceased patient.” The family had gone home, finally to rest, at long last to process their grief. The physicians shake their heads as they pass the empty room.

Where was that fedora now? Probably on the hat rack in his bedroom with the others, gathering dust, waiting for him to come home to it. I take one last look at the picture of the handsome man in the fedora and then move on to the next ICU patient.

Daniel Z. Uslan is an infectious disease physician.

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