Opinion
A PIECE OF MY MIND Susan A. Glod, MD Department of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania.
Corresponding Author: Susan A. Glod, MD ([email protected] .edu). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported. Section Editor: Roxanne K. Young, Associate Senior Editor.
Miracle ECMO row is lined with bodies. I reached between the dialysis machine and the balloon pump to hold the hand of one of them. It was cold and mottled and stiff, and eventually I gave up in my attempts to grasp the fingers and just rested my hand on top of them. Not so for the body’s wife, who had contorted herself to fit between various machines, intertwined her fingers with those of the body’s other hand, and rested her head on its chest, the only part that was still pink enough to resemble her husband. Eventually she stood to let her heavily pregnant daughter take over, and the bile rose in my throat as I watched the cold hand stay frozen in the position she had left it. I wondered how long he had been dead, and whether the grim-faced intensivist, bent over the ECMO cannula, could see what I saw. Failures piled up. The body’s heart, decimated by infarction, would not stop but it would not pump effectively either. Its kidneys failed, its liver failed, it became septic, it did not wake up. Its wife and daughter kept vigil at the bedside and told stories of the body’s life as James: his warmth, his talent for practical jokes, his delight at learning that he was to be a grandfather in the months before his cardiac arrest. They papered the walls of his hospital room with get well cards, notes from well-wishers, and photos of James with his family, on vacation, at his retirement party. They never stopped in their determined attempts to humanize the body. Consultants walked into the room to pass judgment on each failing organ in turn. They walked out again with downcast eyes and held impromptu teaching sessions about medical futility with their house staff. Most gazed empathetically on the grim-faced intensivist as he adjusted flow rates, ventilator settings, and infusions. I was among them.
After a while the empathy turned to pity and, finally, to veiled accusation. Consultants signed off, or promised to follow peripherally. Nurses traded shifts so that none of them would have to spend more than a day at a time in the body’s presence. As the body grew more shrunken and withered, it became difficult just to enter the hospital room, and the muttered complaints, gallows humor, and discussions over wasted resources outside the room escalated. And then came the most difficult thing of all. James got better. It was slow at first, with a brief period of eye contact or a tiny change in laboratory values. After a few weeks, staff who discussed his care started to refer to him by his name instead of his room number. Six months later James strode grinning into the unit, flanked by his wife and daughter, with his infant granddaughter nestled into the crook of his arm. To thank us. To thank all of us who had avoided his room, shirked eye contact with his loved ones, and blasphemed his care plan as we steamrolled over his own goals and values with our own. He survived, but we had still failed him. I coped guiltily by calling James’ outcome a miracle, to which the intensivist waved his hand dismissively. “This is not about miracles. It’s about having patience.” Each body in ECMO row will have a different outcome, blurring the lines between life and death, futility and miracles. We will devote money, time, and emotion, however grudgingly, to those who will not survive. We will cause suffering, we will waste resources, and we will fail in every sense of the word. Every so often, however, a waste of resources will return to the hospital to say thank you. Whether it is through believing in miracles or cultivating patience, we must find the grace and the humility to accept both the thanks and the failure.
jama.com
JAMA April 16, 2014 Volume 311, Number 15
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Indiana University School of Medicine User on 05/11/2015
1499
A PIECE OF MY MIND Susan A. Glod, MD Department of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania.
Corresponding Author: Susan A. Glod, MD ([email protected] .edu). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported. Section Editor: Roxanne K. Young, Associate Senior Editor.
Miracle ECMO row is lined with bodies. I reached between the dialysis machine and the balloon pump to hold the hand of one of them. It was cold and mottled and stiff, and eventually I gave up in my attempts to grasp the fingers and just rested my hand on top of them. Not so for the body’s wife, who had contorted herself to fit between various machines, intertwined her fingers with those of the body’s other hand, and rested her head on its chest, the only part that was still pink enough to resemble her husband. Eventually she stood to let her heavily pregnant daughter take over, and the bile rose in my throat as I watched the cold hand stay frozen in the position she had left it. I wondered how long he had been dead, and whether the grim-faced intensivist, bent over the ECMO cannula, could see what I saw. Failures piled up. The body’s heart, decimated by infarction, would not stop but it would not pump effectively either. Its kidneys failed, its liver failed, it became septic, it did not wake up. Its wife and daughter kept vigil at the bedside and told stories of the body’s life as James: his warmth, his talent for practical jokes, his delight at learning that he was to be a grandfather in the months before his cardiac arrest. They papered the walls of his hospital room with get well cards, notes from well-wishers, and photos of James with his family, on vacation, at his retirement party. They never stopped in their determined attempts to humanize the body. Consultants walked into the room to pass judgment on each failing organ in turn. They walked out again with downcast eyes and held impromptu teaching sessions about medical futility with their house staff. Most gazed empathetically on the grim-faced intensivist as he adjusted flow rates, ventilator settings, and infusions. I was among them.
After a while the empathy turned to pity and, finally, to veiled accusation. Consultants signed off, or promised to follow peripherally. Nurses traded shifts so that none of them would have to spend more than a day at a time in the body’s presence. As the body grew more shrunken and withered, it became difficult just to enter the hospital room, and the muttered complaints, gallows humor, and discussions over wasted resources outside the room escalated. And then came the most difficult thing of all. James got better. It was slow at first, with a brief period of eye contact or a tiny change in laboratory values. After a few weeks, staff who discussed his care started to refer to him by his name instead of his room number. Six months later James strode grinning into the unit, flanked by his wife and daughter, with his infant granddaughter nestled into the crook of his arm. To thank us. To thank all of us who had avoided his room, shirked eye contact with his loved ones, and blasphemed his care plan as we steamrolled over his own goals and values with our own. He survived, but we had still failed him. I coped guiltily by calling James’ outcome a miracle, to which the intensivist waved his hand dismissively. “This is not about miracles. It’s about having patience.” Each body in ECMO row will have a different outcome, blurring the lines between life and death, futility and miracles. We will devote money, time, and emotion, however grudgingly, to those who will not survive. We will cause suffering, we will waste resources, and we will fail in every sense of the word. Every so often, however, a waste of resources will return to the hospital to say thank you. Whether it is through believing in miracles or cultivating patience, we must find the grace and the humility to accept both the thanks and the failure.
jama.com
JAMA April 16, 2014 Volume 311, Number 15
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Indiana University School of Medicine User on 05/11/2015
1499
