End of life

I was asked to to manage this patient's diabetes while he was in the ICU. As my medstudent presented the case to me, things began to sound grim.

This patient, a longtime diabetic on insulin, had a cardiac arrest shortly after a surgical procedure. Despite valiant efforts on the part of the code team, they had difficulties intubating him (congenital malformation of the airway) and then bringing a pulse back. Once they did, he was brought to the ICU. They coded him for over 10 mins, apparently. He was only 58.

Because things happened so fast, when he was apparently doing well, the family was left unprepared for all this. When I went in to examine the patient myself, they were optimistic, talking about how they were expecting him to wake up any day. The nurse, however, had told me that the neurologists had already given them the bad news and that the damage was done, but perhaps because of the shock, they had trouble comprehending the implications.

After I had requested for some private time to examine him with my medstudents, it became very clear to us. I opened his eyelids; his pupils were fully dilated, with no response to light.

When I was a medical resident, one of the things I hated most to do was to 'call' a patient. You check for signs of brainstem reflexes. Verify the absence of spontaneous breathing or a pulse. And then you say, as if to an audience, "Time of death ...".

Being a subspecialist, I tend to stay focused on the matter I've been consulted on, and steer clear of other issues. In this case, it was neither my duty nor my place to try to convince the family of how he was never coming back, and how he was being kept alive only by the ventilator. I don't miss those life-changing and devastating (for the family) discussions about the futility of keeping a patient on the vent. Nonetheless, it was a bit difficult to watch what that family was going through, and knowing what they would eventually go through when it sunk it.

And so, we came up with a reasonable insulin plan for him. And I quietly said a prayer for peace, for him and his family.