The cases you never forget are the young ones, because they are the hardest to let go.
Karyn Woods was thirty-one years old and dying. Three different medications raised her blood pressure to a barely safe range; the ventilator delivered higher and higher levels of oxygen to her lungs. High doses of diuretics failed to make her urinate. Her right heart was failing, a result of longstanding, untreated pulmonary hypertension. Karyn was on no sedative medications, yet she did not wake up when I yelled into her ear. She had made no progress since she was admitted three nights ago for severe shortness of breath.
As the critical care fellow in the medical intensive care unit, I sat in front of her bed with James, a physician assistant. The most recent set of labs confirmed our fears. Karyn's lactic acid level—a measure of tissue damage—had risen to three times the normal value. We had been unable to correct the acidemia with the ventilator. Earlier that day, we had looked into starting her on dialysis to get rid of the excess acid and fluid that were contributing to her demise. Not surprisingly, the renal consult service declined, stating that dialysis was a futile measure. What she needed—and what we couldn't provide—was a new heart and a new set of lungs. What hope we had of saving her was rapidly slipping away.
At this point, James turned to me and asked what we would do if she coded—that is, if her heart went into a dangerous rhythm or stopped altogether. We both knew that this would likely happen to Karyn in the near future. I could envision the event, which I had witnessed many times in the hospital: a mad rush of white coats and nurses, a young intern pumping the patient's chest, residents yelling for intravenous kits and epinephrine. I could see the patient's limbs jerk like a puppet's after the defibrillation paddles were deployed. For a moment everyone would be silent, fixated on the monitor, watching the rapid rhythm fade into nothingness, the hiccup of the blood pressure. And then the chest compressions would begin again. Twenty, thirty minutes of going through the algorithm of drugs, shock, drugs, shock, to end without an intact human life.
Full code—this is the default pathway for every patient who comes to an American hospital. For better or for worse, the medical team performs the drill unless the patient has a legal document saying "do not resuscitate." Most of the time—particularly for young patients such as Karyn—any change to the code status is not addressed until death is imminent.
On television shows, the patient always seems to wake up from a code. In reality, cardiopulmonary resuscitation succeeds in less than 15 percent of hospitalized patients; of these patients who survive the code, an even smaller percentage leave the hospital alive. For a person like Karyn with severe underlying cardiopulmonary disease and profound acidemia, the likelihood of surviving the code is almost zero.
Knowing this, why should a physician perform a maneuver when there is no possibility of benefit? In the same vein, a surgeon wouldn't offer major bypass surgery for someone whose cardiac function was so poor that he wouldn't survive the operating table. And yet our current practice dictates that the default pathway of CPR must be actively discontinued. Although physicians can legally justify changing a patient's code status on the basis of medical futility without patient or family input, in practice this is rarely done.
Short of CPR, Karyn was already on maximal life support. CPR would make her death a violent, chaotic one. It was time to have that end of life talk with the grandmother who kept vigil at her bedside. She was next of kin, the one who'd raised Karyn and now had to speak for her. The attending physician, Dr. Taylor, knew, like James and I, that the likelihood of Karyn surviving the next few days was slim. He planned to meet with her grandmother later that evening to advise her that Karyn's code...