By Dana Freedman

hanging on

Mr. Srinivassana had nine lives.

During this particular ICU stay, according to his sons, daughters, grandsons, granddaughters, great-grandsons, great-granddaughters, nieces, nephews, aunts, uncles and cousins at his bedside, he was on anywhere from life number five to life number seven.  And these nine lives were not based on their Hindi belief in reincarnation—these were not births, deaths, and rebirths over many lifetimes. He did not go from butterfly to bird to pig to dog to human. He survived a very earthly bout of polio, famine, torture as a prisoner of war, tuberculosis, emphysema, and now, lung cancer in his ninety-six years in this body, on this earth. Mr. Srini was ninety-six years old, and, as best I could tell, Mr. Srini wanted to die.

He could not communicate this wish to me verbally. He was “trached”: there was a surgical hole in his neck with a breathing tube inserted directly into his windpipe, bypassing his mouth and throat.   Even if he could have vocalized, I wouldn’t have understood him: my grasp of the Hindi language was limited to food choices,  yoga poses, and a handful of gods and goddesses.

Besides Mr. Srini suffered from dementia, so even if he could have told me, in any language, that he wished to be taken off life support, I was not allowed to let his wishes guide my care of him.  I had to leave that decision to his family, the ones who supposedly knew best what he wanted at the end of his life.  I had no way of knowing what Mr. Srini might have told his children when he was of sound mind and body, but I thought he wsa sending a pretty clear message now, when he looked them in the eye, used his hand to gesture “cut” across his throat,  pulled himself off the ventilator so it alarmed and hissed, or lolled his head to one side and stuck his tongue out to “play dead”.

“Oh, what a kidder you are, dad!” His children would exclaim, then remind him and me of how he once went thirty days on one cup of rice and a quart of dysenteric water. “It’s not time for you to die!”

His family believed in miracles.

There had been so many already. He had survived so much, outlived most of his siblings, his wife, even several of his children. And now he was in an American hospital, under the care and supervision of the finest doctors in the world in a place where miracles happen every day. He would survive. He always did.

I first met Mr. Srini on day three of his ICU stay. He was suffering from an acute bout of pneumonia, an infection in his lungs that had progressed to sepsis, a total systemic infection.  His fever, his heart rate, and his metabolism were incredibly high, his blood pressure and urine output dangerously low. The ICU team had sedated and intubated Mr. Srini, and started him on multiple medications to try to improve his condition.

He had eleven IV drips running when I stepped into his room that morning, including one for nutrition—he weighed only 90 pounds and appeared to be wasting away.  His kidneys were failing. His body was filling up with toxins that his kidneys could not eliminate due to a natural compensatory mechanism. In times of low blood pressure or low oxygen, the body tries to save the brain by drawing all available oxygenated blood away from “lesser” systems like the kidneys and liver. In other words, on the day I met Mr. Srini, he was in respiratory failure, and in renal failure, and on his way toward liver failure, all on top of his baseline dementia and lung cancer diagnosis.

“What are we doing here, folks? I mean really, what are we trying to do here?” This question was posed to the medical team by Dr. Rausch, the incoming attending physician for the ICU service.  At Stanford, attending physicians rotate in and out every two weeks, supervising the critical care fellows who are typically in the ICU for one to two years, and the residents, who rotate in and out on a monthly basis. This was the start of Dr. Rausch’s two weeks on, and I was awfully glad to see him.

One of the residents began, “Well, we’ve started Vanc and Zosyn. We’ve been doing serial lactates, we’ve—“

“No! I mean, good, I’m glad we’re treating his sepsis appropriately. But really!  What are we doing to this poor man?”

The residents shuffled their feet and looked down at the floor.

“Look at him. Look at your patient. He’s what, eighty-something?” He looked down at his notes, “Ninety-six! Ninety-six years old! This man is ninety-six years old with dementia, emphysema, lung cancer. He’s cachectic—when’s the last time this man enjoyed a meal with his family? When’s the last time this man enjoyed anything?”

He paused for a breath, took his energy down a notch. “Of course, we can’t answer those questions ourselves. But we need to be thinking about them, we need to be asking them, we need to be asking our patients and our patients’ families these questions before we go intubating and sedating and dragging the half dead elderly to the ICU for two weeks of torture before we finally let them go.”

No one moved. A few nodded their heads as they continued to stare at the floor.

“This man is a full code. Look at him—he’s going to code before this day is over. And you are going to ask this young lady” (he pointed to me) “to pound on his chest, to break his ribs, to cause extreme pain, to keep blood circulating in a ninety-six year old body for one more day. Why?”

Again, no responses.

“We need to have a talk with his family today, first thing after rounds. That is what we need to do for this poor man. Dana, do you have anything to add?”

“No, Dr. Rausch. Thank you,” I said.

He nodded  and led his brace of white-coated ducklings out of Mr. Srini’s room.

After a year as a student nurse in this ICU, and six months of practicing on my own, I had a good sense of most of the attending physicians. I knew one doctor to be incredibly stingy with pain medication. We had to fight to keep her patients comfortable. Another doctor, Dr. Pfaff, believed that nurses were among the lowest of life forms. He wouldn’t hesitate to tell us so, and he tried to instill this bias in his residents.

This same charming doctor believed that it was not his job to withdraw life support. Ever. It was God’s decision to end a life. It was his role as a man of God to do everything he could to preserve it. This translated practically into starting continuous dialysis on 96-year old cancer-ridden demented patients, as we ended up doing with Mr. Srini under his care, or floating invasive lines into the hearts of the clinically brain dead. This particular doctor was the man who admitted Mr. Srini to the ICU without a single conversation about the possibility of making him comfortable and letting him go peacefully.

Dr. Rausch, on the other hand, was one of the good ones. I always breathed a sigh of relief when he stepped into my patients’ rooms. He was an incredible teacher, a good listener, realistic, honest and straightforward, yet gentle, kind, and sensitive to the needs of patients, families, and members of the caring team in times of crisis. But not even he could save Mr. Srini from further torture. When a family believes in miracles as firmly as Mr. Srini’s did,  “miracles” like Mr. Srini can linger in the ICU for months, even when physicians are willing to have important conversations about end-of-life and hospice care.

And linger he did. I suppose you could call it a miracle that Mr. Srini survived that first bout of sepsis. To keep his heart from stopping, to keep him from coding that day I pumped him so full of fluids that he bloated and swelled beyond visible recognition. I pushed ampule after ampule of sodium bicarbonate, a chemical buffer to temporarily counteract the acidity of his blood. Yes, miracle of all miracles, he survived that day, and the antibiotics kicked in, and the infection improved. But his body was so weakened that he was never able to breathe on his own again, his kidneys never recovered and he required continuous dialysis. He was “trached and pegged”—a tube inserted into his neck to breathe through, as I mentioned earlier, and another inserted into his stomach to feed him. Two months passed, then three months passesd, and Mr. Srini was still in intensive care.

Nurses fought over who had to care for him. It was a horribly depressing assignment to have to care for someone who no longer wants to be alive, but whose family refuses to let go. It was almost unbearable to listen to his family members talking to him, “Oh, dad, you’re so funny! You’re not dying! Ha ha ha! You’re going to come home soon!” It was unbearable to have to watch Mr. Srini grimace and sneer at his loved ones as they talked in voices two octaves higher than what’s natural, the way you might talk to a baby or a pet. We had to tie his hands to the bed, “restraints” as they are called in the hospital setting, to keep him from pulling himself off of the ventilator, from ripping his IVs out, which he did many times, even though we all wanted nothing more than to take him off the ventilator and hold his hand and let him go. Eventually he became too weak to even raise his hands off the bed, and we were able to leave him free. For a month all he could do was turn his head to look at the wall whenever a family member spoke to him. Eventually he couldn’t even turn to get away.

The newly formed hospital ethics committee was called in at the behest of the nursing staff and Dr. Rausch, but when a family refuses to withdraw life support in a patient considered unable to speak for himself, there is very little that can be done. The lack of consistency in the messages being sent to the family did not help matters either. When Dr. Rausch went off service, he was replaced for two weeks by Dr. Ahlawat, who was, in general, less involved and less vocal with patients’ families. He was a kind doctor, and benign as far as the nursing staff was concerned, but somewhat ineffective when it came to difficult conversations. When Dr. Ahlawat was on, nearly everything remained status quo on the unit until another, more opinionated or proactive physician took his place. Of course, Dr. Ahlawat was followed by my favorite “nurses-don’t-know-anything-and-we-are-in-the-business-of-saving-lives-not-ending-them” doctor, Dr. Pfaff, and we were back to square one. What the ethics committee did manage to accomplish under Dr. Rausch’s care was change Mr. Srini’s code status from “full code” to “DNR”—do not resuscitate. This meant that we would not have to break his ribs when his heart finally stopped.

In the meantime, weeks continued to pass. Mr. Srini ceased to open his eyes, or follow commands. His digestive tract halted and the beige liquid we pumped into his feeding tube to nourish him pooled and collected into his stomach until we suctioned it out again, every two hours, to prevent the fluid from coming up his esophagus, and heading down his windpipe, leading to another pneumonia. What did leak out his back end looked and smelled undigested and unchanged—the same stuff that went in came back out again. He weighed 75 pounds by now, was yellow with jaundice, and on continuous dialysis and the ventilator. Not a single organ in his body was functioning on its own.

By the third month, Mr. Srini began having seizures. There was a strong likelihood that during his stay his lung cancer had metastasized to his brain, but he was too sick and too unstable to be taken to the MRI scanner to confirm this, and there would certainly be no treatment to offer if it had. This didn’t stop Dr. Pfaff from ordering the MRI, of course, but the nursing staff refused to take him to the scanner.

“If you want to take him to MRI, you can take him yourself, but he won’t come back alive,” his nurse, Anne, told the resident. Later she shared with me the thought that had crossed her mind—maybe she should just take him, to put him out of his misery, but she knew the move would cause him so much pain that she couldn’t bring herself to do it.

On my final shift with Mr. Srini, Dr. Rausch came into the room for rounds. He looked at what was left of Mr. Srini lying in the bed, the equipment in the room, then back at his team of young doctors, shook his head, and walked out the door.

“I have nothing left to say.” Then he paused and turned toward me. “Do you need anything from me, Dana?”

“I don’t think so, Dr. Rausch. I’m thinking it’s time to give Mr. Srini a bath.”

“Please do.”

When a person is at the end of life, just the gentle stimulation of a bed bath can sometimes tip them into letting go.  Anne was afraid to take Mr. Srini down to the MRI scanner because she knew the movement from bed to scanner table would surely lead to his death, but she also knew it would cause him a great deal of pain. I didn’t wish to cause Mr. Srini any more pain, but if I could help him exit swiftly and comfortably, I would.It was worth a try.

I drew up a basin of warm water with baby shampoo and washcloths and gathered blankets and towels to keep him warm and dry. I enlisted the help of my float nurse, Marie, to help me move quickly, and to change his position in the bed smoothly, without any jerking motions. I washed his hair, massaging his scalp and neck, towel dried him, then worked my way from his head to his toes, uncovering his emaciated body parts bit by bit, long enough to wash, dry, and tuck them back under clean blankets again. When it came time to turn him to expose his back, Marie and I held our breath and looked up at the monitor. His heart immediately changed rhythms, climbing first in rate to the 160s in what appeared to be a supraventricular tachycardia, a non-deadly, though dangerous rhythm, then slipping into a run of v-tach, the deadly one. I wiped his bottom, then suggested we return him to his back again, to see what happened next.  His heart rate remained elevated in the non-deadly rhythm, then slowly drifted down to a regular rate before switching back into another run of v-tach.

Wash. Rinse. Repeat.

“I’m going to bring in the family.”

Later that afternoon—three months, four days, and nine hours into his ICU stay, Mr. Srini finally received his celestial discharge. For all the time I had spent with him, I never had the chance to know whether or not he believed in reincarnation, and in what form, if any, he wished to return.

Dana Freedman is a critical care nurse who spends several nights a week in a helicopter flying over the Bay Area, saving lives.  By day she keeps busy as a single parent to a 1-year old boy and a pair of back-talking huskies. In all of her spare time she is writing a memoir. The Kind of Woman Who Would is a story of love and relationship, death and dying, and what to do if you should find yourself single at 39 with a desperate longing for motherhood. With any luck, and a few stolen moments, it should be finished in early fall.Dana

 

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