Time's up

Last evening at 3am during a moonlighting shift, (translation: extra work as an in-hospital overnight doctor for the money I need to sustain my family), I got a call from the ICU that every doctor dreads. The conversation went something like this:

Nurse: "Doctor, patient X has no traceable blood pressure, is on multiple pressors [medications to maintain his blood pressure] and has blue hands now. His wife is in the room and would like to speak with you."

Me (half asleep in between admitting 7 patients in the emergency room): "Why is he on multiple pressors? Why is he in the ICU?"

Nurse: "He coded 3 times today and underwent CPR for an hour with multiple defibrillations (shocks) and then had a full pulseless arrest and then finally came back with multiple resuscitation attempts and is now intubated [on a breathing tube] in our unit."

Me: "And the family knows his outlook and wants our aggressive care?"

Nurse: "Well- I'm not sure...."

Me (now much more awake): "I'm on my way."

So I arrived in the ICU, room 12, to find a kind woman sitting calmly at the end of my intubated patient's bed. His hands were indeed blue. That was secondary to our medications. His breathing was 100% automated by our machine. How much brain function he had remained unclear, but he was 85 years old and had undergone over an hour of intense resuscitation requiring the cracking of several ribs during CPR, placement of invasive lines, strangers hands everywhere- in every orifice- in an ignorant attempt to cheat the inevitable.

Of course, at 3am, standing before his wife of 58 years, who was I to judge or divulge? Will I not, one day, faced with the exquisitely painful moment of my own spouse's death, ask for anything and everything possible to relieve me of all of that? Believe it or not, I don't think so. The truth is, in these years, seeing so many bodies take their last breaths (as every doctor does over time), I understand clearly that life ends, and that it is not up to us to decide when. I've seen wonderful 30 year old mothers die with their husband and toddlers at her side. And I've seen miserly old women die friendless and alone. And in both cases, the body could no longer sustain itself. As clear as it could be in these instances, it was time, even if the death itself seemed untimely.

In the next 10 minutes, I discovered everything. I found out that they met in high school. That he smoked and that she loved that about him. "It made him seem so cool" she told me. "And he was cool." Certainly it sounded that way to me. This man, who had worked construction before becoming a successful building inspector- had started a business with his own hands and become a complete success. And his daughter, weeping quietly in the corner, proved that he was leaving a compassionate legacy that will carry his name and his DNA forward.

Then I laid out the prognosis: that he would surely be dead in a matter of hours. I am not cavalier about divulging such statements. In fact, I, like most of my peers, hate to prognosticate as we doctors take the huge risk, when doing so, that we will face anger from families and our own guilt if we are wrong. But in this case it was inevitable that he was dying. So I asked his wife what he would want, in his final hours.

"Not this," she said, "god not this."

Within an hour the tubes were removed, and the lights dimmed, and a quiet room was established where his 3 daughters now sat with their mother beside him. A final family moment before, like the cobalt sky of pre-dawn, he was gone.