Jesus on the night when he was betrayed took bread, and when he had given thanks, he broke it and said, “This is my body which is for you. Do this in remembrance of me.” —1 Corinthians 11:23–24
We never spoke and were never formally introduced. I didn't even know her name. But when the CPR ended, I held her hand as she died.
The cardiovascular intensive care unit fellow had texted me 45 minutes earlier, making sure to leave out any personal identifiers including her name. We had to be careful not to violate the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Violations of HIPAA could mean fines of tens of thousands of dollars. Worst case, a doctor could do time in federal prison.
I knew she was more than 80 years old and had come in with an ST-elevation myocardial infarction (STEMI). I learned that she lived in hospice and carried a diagnosis of dementia.
“Medicine svc?” I texted the fellow.
“Medicine won't take STEMI” was the reply. “ER called STEMI.”
Calling the interventional team in the middle of the night for this? What about her dementia? What about the hospice? What were we doing? Experience told me to get dressed and head to the hospital. I arrived in the emergency room in less than 10 minutes and met the nurse who had accompanied the patient from hospice.
“She is not DNR,” she told me. “The family had discussed it in the past but couldn't reach an agreement.”
“She is in hospice?”
“Yes.”
“But she is not DNR.”
“Yes.”
I quickly moved to the nurses' station and grabbed a phone. I dialed the family contact listed in her electronic health record, a daughter who lived in a town nearby.
“This is Dr. Michel calling from the hospital.”
“Yes? How is Mom doing?”
“Well, she is having a big heart attack, and I wanted to talk to you about that. I wanted to make sure that we are doing the right thing as we work to take care of her.”
“Thank you. Well, of course. Please do whatever you think you need to do.”
“Okay, well, that would mean taking her down to the lab and putting tubes into her arteries and trying to open the blockage causing her heart attack.”
“Okay.”
“But I wanted to make sure that she and you, … that the family would want that.”
“Of course! We want you to do whatever you need to do to save her if you can.”
“But she has dementia? And is in hospice?”
“Yes. I saw her today. She seemed fine. She didn't mention feeling at all sick. Of course, she doesn't talk much. But she seemed happy.”
“And she would want to be treated aggressively?”
“Is there a less aggressive treatment that would work?”
“Well, no.”
“Okay then.”
“Okay.”
The mechanical drives clanged as heavy doors opened, revealing the large trauma bay. Small, thin, pale, and gray, my patient lay motionless in a heap on a gurney, the center of attention. A heavy-set nurse towered over her, arms extended, applying 100 compressions a minute to her chest in guideline-perfect order. I thought I heard an occasional crunch. Ribs breaking? A respiratory technician stood near her head using a black bag to force air into her lungs.
I felt some relief. Perhaps this would end here and now.
“I have a rhythm,” an excited ER resident exclaimed. “Stop CPR.”
“Let's get her to the lab!”
I had to move quickly to avoid being run over as patient and gurney, propelled by a stampede of physicians, nurses, and technicians, erupted from the room.
Time is myocardium. Door-to-balloon time is a quality metric. Our exceptionally fast door-to-balloon time makes us a top 50 hospital. We are number one in patient satisfaction. I remember seeing all this and more on a billboard once. Metrics and reputation on the line.
The interventional team awaited us. Three gowned figures stood like statues as we flooded the catheterization laboratory and adjacent control room.
“STEMI!” Their pagers had gone off 30 minutes earlier, calling them in to perform interventional last rites, a Viaticum, in honor of this woman whose life would end tonight.
In the Catholic faith, the dying are anointed with holy oil, given the Eucharist and offered absolution for their sins in the hope of a safe passage into heaven. But holy oil and Eucharist are not on our formulary. And priests? I am sure we have none.
“Do you want a balloon pump?”
I worked hard not to say something sarcastic—something smug, cutting, and disrespectful. Did our Viaticum require a balloon pump? I thought not.
“I say no to the balloon pump. Let's get the artery open and see how she does.”
We had no power to anoint or absolve. There were no prayers. There was no moment of silence. No family member spoke.
Metrics would be obtained. Quality measures weighed. Had we protected her medical records? Would her satisfaction be high or merely average? Would she recommend us to family and friends?
Betadine swabbed her groin. A sterile drape was laid down, reducing her to a small circle of pink flesh. Our bearded interventional fellow plunged a large needle into that flesh and maneuvered until a small geyser of blood erupted from the hub. A wire was passed, then a catheter.
“What about an Impella? Her pressure sucks.”
We opened up her IV, and warm salt water ran into her veins as quickly as gravity would allow.
“Start dopamine.”
On the monitor, I watched the catheter climb her aorta like a snake. The interventional fellow deftly maneuvered the catheter around the arch of the aorta and into the ostium of the right coronary artery. Dye flowed and a whirring mechanical sound indicated that pictures were being recorded. Thrombus had obstructed the artery in its mid portion. A small wire was quickly inserted and soon emerged from the catheter tip, worming its way down the artery and across the blockage.
“We've lost her pressure. Start CPR!”
Our catheter registered reassuring pulsations. But her heart had stopped. Her sinus node screamed. Her ECG showed electrical gyrations amped up by the dopamine and epinephrine we had given her. But after a lifetime of constant motion, her heart relaxed and would beat no more.
Death was with us and for the first time we fell silent.
I found her family huddled in the waiting room. They seemed like nice people. I recounted the timeline of her death. They cried and hugged each other. Then they hugged me and thanked me and my team. For what? We had not saved her.
And only then I heard her name.
“Joanne.”
Rest in peace, Joanne.
VIATICUM REDUX
Although the first story is how the scene played out, here is how it could have happened.
Be kind and compassionate to one another, forgiving each other, as in Christ God forgave you. —Ephesians 4:32
We never spoke and were never formally introduced, though I did know her name—Joanne. Lying peacefully, her daughter by her side, she held my hand as she died.
The cardiovascular intensive care unit fellow had texted me 45 minutes earlier, making sure to leave out any personal identifiers, including her name. I knew she was more than 80 years old and had come in with a STEMI. I learned that she lived in hospice and carried a diagnosis of dementia. I arrived in the emergency room in less than 10 minutes and met the nurse who had accompanied the patient from hospice.
“She is DNR,” she told me. “The family has discussed it and are all in agreement.”
“Okay, good.”
I quickly moved to the nurses' station and grabbed a phone. I dialed the family contact listed in her electronic health record.
“This is Dr. Michel calling from the hospital.”
“Yes? How is Mom doing?”
“Well, she is having a big heart attack, and I wanted to talk to you about that. I wanted to make sure that we are doing the right thing as we work to take care of her.”
“Thank you. Well, of course. Please do whatever you think you need to do.”
“Okay, well, I think we need to take good care of your mom by controlling her pain, giving her oxygen, and working to make certain that if this is the day that God calls her home, as I believe that it is, that she has safe passage. You might want to come to the hospital to hold her hand.”
“Thank you. I am on my way.”
“4 mg of morphine” I called out as I held my arms high, waving away the swarm of physicians gathered around our patient.
“Comfort measures only! No cath. Tell the team to go home.”
We moved her out and away from the noise and confusion of the ER. Flowers and birds played across a wallpaper forest that decorated her room. Soft music played and she was surrounded by pillows. She was calm, breathing softly but evenly, bundled in soft sheets and warm blankets.
The chaplain joined me and we took advantage of the calm and quiet to review her chart. I learned her name, Joanne. She had been married but her husband, Thomas, had passed away last year. She had three children: Susan, Mary, and Elizabeth. Susan, the daughter I had spoken with by phone, soon joined us. Together we sat on either side, holding her hands in ours.
As the minutes passed, her breathing became weaker and more shallow. Her face showed neither pain nor fear. Her eyes opened slightly from time to time. At times she murmured. After 30 minutes or so she slipped away. I swear that I saw her smile at the end.
“You will be with Papa soon,” Susan told her as she held her hand. “We love you.”
“Rest in peace, Joanne.”