Time of death

I watch a lot of movies and a lot of television. One of my favorite shows is M*A*S*H. I can't remember when I started watching M*A*S*H. It must have been on Nick at Nite. But, I eventually bought the box set and I've watched every episode a dozen times. I can quote it, I can give the blow-by-blow of most episodes. But, there are some episodes that stick with me more than others. One in particular is a Christmas episode where an injured soldier is flown into the unit during a party on Christmas Day. Colonel Potter, BJ, Hawkeye and Hot Lips keep everyone else in the dark while they try and save this man. Eventually they realize that he can't be saved and they instead settle for keeping him alive just long enough so that his kids don't find out that their father died on Christmas. Unfortunately the soldier dies just before midnight. They bluff the death certificate anyways. It's a good episode. One of many good episodes. But, like I said it always stuck with me.

Last night while I was on call I replayed scenes from that episode over and over again. When I got sign out for the Thoracic Surgery service I was told that one of the patients was circling the drain and that I would be notified when the decision to withdraw care occurred and that I would be required to pronounce him and fill out the death packet. This was the 4th and last time I'd cross-covered for Thoracics this month and I knew this kids story.

He was a 20 year old Cystic Fibrosis patient. He'd actually had a relatively benign course with the disease up until about 8 months ago when his lungs started tanking. But, about a month ago he got a bilateral lung transplant. And we thought that he'd stabilized and would continue being a healthy kid until he suddenly started getting sick again. A couple of biopsies later and we realized his right lung and a horrific necrotizing pneumonia tearing through it. He and his family made the decision to have that lung removed even though it meant that they would be off the donor list instead of waiting for another new set of lungs which would probably have been too late anyways.

Now, our boy might have rallied until one of the lines he had in him grew out a couple of multi-drug resistant organisms and he ended up septic. We loaded him up with 8 different antibiotics by the end of his course in an attempt to stop the bugs tearing his system to shred. But the CF had left him so weak he couldn't mount his own immune response. Not to mention that we couldn't keep his respiratory status up.

This was the story my co-intern presented me with on Sunday morning. Now, my co-intern is doing his intern year in surgery before moving onto the good life in Radiology. He chose a much harder specialty than he had to and he works harder than I've ever seen anyone work. In addition he's married with a daughter at home who is only a few months old. He's pretty strong guy but I was afraid he was going to break down while he was telling me about this patient. He asked that I keep him updated as changes were made for this patient. So when the family made him DNR/DNI I called him and when we de-escalated care later that night he said he was coming in.

He paged me when he got to the hospital and I stopped by the unit to check in on him and the patient. My patient's whole family was crowded around his oversized ICU bed and I felt like a voyeur looking in on them. I sat next to my co-intern and we talked about who should pronounce the patient and who should fill out the patient. He wanted to take that responsibility and as much as I didn't want to do it I was the one that was on-call and it was my job that night. Not to mention that as hard as it was going to be for me it would have been ten times harder for him. I hadn't spent the last month following this patient and watching him get sicker and sicker. Watching as every intervention we tried failed and sometimes even seemed to make things worse. That was what my co-intern was already struggling with that night. I wasn't about to add to his burdens for my peace of mind.

So at quarter to 2 when I got the call from the Thoracic ICU saying it was time I went there to do something I wasn't remotely prepared to do. The whole time I was walking over from the children's hospital to the TICU I kept trying to remember the words that are used when we pronounce someone. I couldn't find the right ones. I kept thinking "I now pronounce him dead," or "This man is pronounced dead," or "By the power vested in me." It sounds ridiculous but I could not get the words right. Then as I swiped my ID badge to enter the unit the words hit me "Time of Death ..." But then I realized that I didn't know what I was supposed to do before that. They don't teach us this in med school. I know what criteria must be met in order to determine brain death vs cardiac death. Was I supposed to check his brain stem reflexes or just listen for a pulse. I was frozen in the doorway of the TICU trying to figure out my next move.

I knew that the way I handled this could make an awful experience for this patient's family ten times worse. I grabbed one of the ICU nurses and pulled her aside asking what I should do. She told me to listen for a lack of heartbeat and check that there was no peripheral or central pulse and then call it. I asked if her just had to say "Time of death" or if there was anything else. I wanted to talk to her for a few more minutes to by myself some time. But the family was waiting and she ushered me into the room.

I tried to introduce myself but the looks on the faces of his family left me tongue tied. I mumbled my name and walked to the edge of the patient's bed. After years of patient contact my first instinct was to say loudly "Hello, sir, I'm just going to lay this stethoscope on your chest and take a quick listen." I always tell my patients what I'm going to do to them, even the comatose ones. But, knew that this was not a situation where that would be appropriate or appreciated. I placed my steth on this young man's emaciated chest and heard . . . nothing. No heartbeat, no lung sounds. At first I thought my steth was broken. I might as well have placed the bell on his bed for all I was hearing. And then I realized that nothing was what I was supposed to be hearing. I checked for a radial and central pulse but without a heart beat it seemed a little redundant.

Then I looked up and without realizing it directly into the eyes of this young man's Father and said "time of death 0200 hours on september 27th, 2010." Dad started crying his sobs mingling with the tears his wife had been crying since I'd met her earlier this morning. His younger sister looked shocked as she leaned against her mother's chair. The various grandparents, aunts, uncles and cousins crowded into the room were crying or standing their stoically waiting for me to leave. I mumbled how sorry I was for the loss. My words sounding hollow in the face of their grief.

As I walked out of the room a nurse handed me a stalk of papers and told me my co-intern was on his way down. I wanted to get the bulk of the death packet taken care of before he arrived but I also wanted to break down and cry. This time I couldn't wait till I found a supply closet. I sat down at the nurses station, put my head down and let the tears come. Then I started on the paperwork. It was painful and made even more difficult when I realized that I still had questions for the family. Such as, did they want an autopsy, was it okay of I called donor services?

I somehow got through most of that and my co-intern arrived right as I got paged to check on another sick patient (who later had a rapid response called on him and got transferred to the SICU, it was not a good night). I was done. I had survived my first pronouncement. About 6 hours later I got a stat page to come to the TICU. I had a few more forms I needed to sign. I was on rounds with my attending so I rushed into the unit hoping to get this taken care of quickly and stopped in my tracks. My patients room had been cleaned and was already housing a brand new patient. It as surreal. I wondered if this patient knew about the previous occupant and how that would make them feel. I signed my papers and left.

When I got home this morning I tried to sleep but all I kept hearing was my voice falling on deafening silence saying "time of death 0200 hours."