His Death Would Not Be a Good Death

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This story is from the Anamnesis episode called A Moral Code: Ethical Dilemmas in Medicine at 2:31 in the podcast. It’s from Cedric Dark, MD, MPH, an emergency medicine physician and an associate professor in the Henry J. N. Taub Department of Emergency Medicine at Baylor College of Medicine in Houston. He is the author of the book, Under The Gun: An ER Doctor’s Cure for America’s Gun Epidemic.

Death is sometimes welcomed by the dying. Some, like my Uncle Bobby, with a long protracted metastatic stomach cancer, welcome the relief from pain and suffering. For others, such as my Uncle Robert, death rocks the family like a sudden quake erupting from faults, or in his case, a long hidden coronary plaque. But being in a persistent vegetative state, still warm and seemingly alive to the untrained onlooker, seemed to me like the ultimate state of limbo.

That was a state my patient existed in as I lumbered into a family room located adjacent to the intensive care unit. A large contingent had assembled and the duty had fallen on me, as a mere resident, to tell them that their loved one, a young army soldier, a husband, a father, and an uncle, would never wake up. They had little time to emotionally prepare for this outcome. Sudden death rips at our emotional core precisely because we can’t prepare for it.

We Too Have Lived These Horrors

As physicians, we are taught to empathize with our patients and their families when the worst moments in life strike. We too have stopped, walked away from everything and cried over the loss of family because we too have lived these horrors. But upon entering that family room, I hadn’t yet lived enough life to personally know that anguish.

Despite being a soldier, this man had never deployed in his year and a half in the army. He wasn’t supposed to die. He had never seen combat. Instead, he had put the gun to his own head, but the bullet missed.

Because his skull had shattered into innumerable pieces, his brain didn’t herniate. The skull is inflexible and unyielding like a bank vault. Inside resides three things: blood, cerebrospinal fluid, and brain. The blood feeds the brain nutrients, sugars, and oxygen that fuel our thoughts, our wishes, and our desires. And our insecurities.

The cerebrospinal fluid, a clear water-like substance, floats the brain safely inside the confines of this vessel, preventing it from slamming violently against the walls of the skull and injuring the soft squishy material that houses our consciousness. After trauma, either the brain will swell or hemorrhage will increase, ultimately putting pressure on the brain itself until it crashes downward through the bottom of the skull, crushing the brain stem until it can no longer perform basic, vital functions like breathing and controlling the heartbeat.

Instead, my patient’s brain swelled tremendously without ever abutting the inside of the vault because the walls of that vault were too shattered. Inside the ICU, we all suspected he would continue in a persistent vegetative state, receiving ventilatory support and continuous instructions from his brain stem. His heart and lungs would remain functional, even though his consciousness had long slipped away into oblivion.

Knowing When to Let Go

With my patient having first arrived on Monday, the nurses had been performing a 48-hour dressing change on Wednesday when they called me to the bedside to witness something I had never experienced in my brief career to that point. As soon as the pressure dressing was taken off his head, the brain oozed out of the wound. It was the color and consistency of white toothpaste.

I’ve witnessed a lot of gun deaths over many decades, working in an urban emergency department riddled with the daily trickle of gun violence. But this one was different. All I can say is, thank God his mother wasn’t there that day. Telling a mother that her son had been shot dead, that never gets easy. But informing the rest of his family was no easy task either.

Later in the afternoon, our team sat down in a quiet room with my patient’s wife to inform her of the poor prognosis.

Despite three different physicians telling her that he would never get better, she wouldn’t allow us to change his code status. The concept of letting him die was foreign to her.

But inside the hospital, these critical discussions occur frequently. They’re absolutely necessary. Should we do everything in our medical power to try to bring a dying patient back to life? Administering epinephrine, placing a breathing tube in the windpipe? And pumping on the chest with our hands doing CPR?

Occasionally you hear miracle stories of people who are essentially raised from the dead and returned to life as good as new. But successful CPR in these situations is the exception, not the rule.

As Wednesday passed into Thursday, I thought to myself, what good would CPR do for this man if his heart stopped beating? It would be futile. His brain wouldn’t miraculously heal.

It felt as if patient autonomy, in this case the decision from my patient’s wife, had trumped our professional medical opinion. Maybe the grind of being on call every third night for weeks without end had finally began to take an emotional toll. Physical exhaustion, coupled with the weight of seeing patient after patient die in the trauma ICU, is enough to make you want to do what you know is inevitable for your patient. Even when it’s against the family’s wishes. I was so tired of my efforts being futile.

The Struggle for True Empathy

I had seen good deaths, like the elderly Buddhist man who had lived a long and full life and whose family stood by his side as he transcended into death. And I had seen tragedies, a 19-year-old kid with relatively minor injuries after the brakes of his car gave way. He was fine, but his girlfriend had been killed.

But this guy? Full code shouldn’t even have been on the table. I understood that the sudden shock of his suicide attempt was perhaps the reason his wife was so unwilling to let him go.

Gun violence, albeit self-inflicted, had struck swiftly and unexpectedly, like it does to tens of thousands of Americans every year. How many lives had that single bullet altered? His? His wife’s? His son’s? The list goes on.

After delivering the bad news to the rest of the family, my patient’s niece, who was just 17 years old, came up to me with tears streaming from her eyes. Her voice choked. “How can you do it? How can you tell people that someone is dead?”

Her question startled me. “It’s part of the job,” I replied ineptly, with the immaturity of my experience. “We’re here to make people feel better — sometimes who we help is a family.”

She told me that she wanted to become a doctor. The emotions she felt were not for herself, but for her cousin who had just lost his father. I stood amazed at her genuine loving expression of empathy.

I struggled at the time to achieve true empathy. I like to think that even the best of us struggle with it. Although the explicit curriculum in medicine demands it, the hidden curriculum implores us to avoid losing control of ourselves. Sympathy comes easier. We can express simple condolences to the patient or family. But it’s sometimes impossible to put oneself in another person’s shoes, to feel what the other person feels.

Nearly two decades have passed since I had that conversation with my patient’s niece. I’ve gotten better at empathy, perhaps because of the losses I’ve experienced since that moment. And while some situations come easier than others, many remain unbelievably difficult.

As for my patient, well, whenever the inevitable would arrive — whether later that night, the next day, or in the weeks, months, and years that would follow, long after I was gone from the ICU — his death would not be a good death. For his niece, who spoke to me with tears drowning her youthful face, it would be the first in a long line of difficult conversations she might one day claim is just part of the job for someone who dons the white coat and whose duty it is to save lives and relieve suffering.

Check out the other stories from the A Moral Code: Ethical Dilemmas in Medicine episode, including “Should I Offer My Patient the Option to End His Life?” and “We Don’t Always Know What’s ‘Best’ for Our Patients.”

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