Sunday, October 3, 2010

Eight Minutes

"She's 74 with end-stage lung disease," the ICU resident told me over the phone. "BiPAP-dependent, unresponsive, and the family is thinking about withdrawing care." Meaning, Molly wasn't expected ever again to breathe well enough on her own to survive. She was wearing a tight-fitting mask that helped push air in and out of her disease-ravaged lungs; if that were removed, she probably would die within hours. She couldn't be aroused. She had five adult children who now understood that their mom had come to the end of the line.

I gently chided the resident about the phrase "withdrawing care," which I detest -- as someone wiser than me once wrote, we may withdraw certain forms of treatment, but we never withdraw care -- and told her I'd come meet with the family. A son and a daughter were at Molly's bedside. We moved to a small conference room so that I could review the situation. They understood that she would never want to be permanently connected to a breathing machine. One by one the other three kids arrived. I did the same review three more times, spending over two hours with Molly's family. In the end, they agreed on a comfort approach. The BiPAP would come off while their mother received morphine to ease the work of breathing. If she kept breathing on her own, she'd come out of the ICU and would transfer to our acute palliative care unit. To everyone involved, me included, this seemed the most compassionate choice.

And so it went. The morphine was started around six that evening, the BiPAP was removed and an ordinary oxygen mask substituted, and Molly actually continued to breathe without apparent distress all night while maintaining an adequate amount of oxygen in her blood. I came by early the next morning, verified our intentions, and asked the ICU staff to get the transfer going.

Now, in a busy intensive care unit, the top priority is not usually transferring a patient whose care had been "withdrawn" to what some think is the elephant graveyard of the hospital. About four hours passed between my thumbs-up in the ICU and the time Molly arrived on the palliative care unit. I looked at Molly, looked at the orderly pushing the gurney, and said, "Hurry up." She was gray and, I thought, minutes away from death. The orderly hurried. We got her into bed just before the kids arrived.

Our head nurse joined me in Molly's room as the children circled the bed. In turn, each began to say his or her good-bye. When the second child had finished, my experienced eye told me something had happened. The nurse and I exchanged a glance that said: Our patient has just died.

But the good-byes weren't done. It was the turn of the third one, and then the fourth, and then the fifth. Just as the last child finished speaking, I looked at the clock. Eight minutes since Molly had died. I reached for my stethoscope, moved to the bed, and listened for a heartbeat I knew would not be there. And then I said: "That was so extraordinary. I was watching your mom as each of you spoke. Just as you all finished, I could tell that she was taking her last breath. Obviously she waited to say her own good-bye until all of you had said yours." Molly's five children nodded, and cried, and held each other for a long time. The nurse and I expressed our sorrow for their loss and accepted their thanks for making their mother's passing a gentle one.

Then I left the room and falsified the medical record and the death certificate, listing the time of death as eight minutes later than it actually happened.

My profession values truth, and not being truthful on a death certificate is probably a crime. What would you have done?


  1. is there any hospice drs in north carolina?

  2. Every hospice has a medical director, but not all hospice medical directors have specialized knowledge of the field. You can call a local hospice and ask if its medical director is board-certified in hospice and palliative medicine. I don't know where in North Carolina you're located. Your local hospital or a nearby medical school might be able to direct you to experts in the field.

  3. Hospice & Palliative Care Charlotte Region has wonderful physicians. We serve 8 counties from 5 locations. If you are anywhere near the Charlotte area, contact us if we can help. 704.375.0100.

  4. Good blog, HD.
    As the Coroner in the Wizard of Oz phrased it when he pronounced the Wicked Witch dead, she was "not just merely dead but really quite sincerely dead." There's someting to be learned there.
    Patient's aren't dead until a physician pronounces them dead. There's nothing wrong with waiting 8 minutes to be sure. Once one of my hospice inpatients didn't quite die until the smoking family members in the parking lot were hurried into the room - they had wanted to be present "when." Strangest thing, the heart slowly kept beating - I controlled the stethoscope - for those few minutes after breathing had ceased. Happens, once in a while. Another time, different patient, the nurse announced the death just before a daughter raced into the room, and I immediately told the daughter "Go ahead and say goodbye - he can still hear you for a minute or so." I truly don't believe I was wrong - the body's systems don't all cease simultaneously. (Otherwise, CPR would never work.) The art is in interpretation.
    South Bend Hospice Doc