Illusive Hope

During my last weekend call, one of the many admissions I had to the ICU was a man in his 70’s, who was found unresponsive in his home. Since he lives alone, he probably have been lying on the floor for a couple of days before he was found.

After work-up in the emergency room, it was determined that he had a large stroke. As he was very sick and unstable, we were consulted to admit him in our ICU.

The next day, after providing supportive measures, his vital signs stabilized and he became more responsive, and even following simple commands. Yet he still has significant neurologic deficits due to the devastating stroke.

The patient’s son who was the power-of-attorney, talked to me and showed me his father’s living will, which specifically detailed that in case he had an “irreversible condition,” he does not want to be on any form of life support including artificial nutrition, like tube feedings or even intravenous fluids.

I assessed that with the severity of the stroke, the likelihood of “good” recovery was doubtful. My projection was that he would never live independently again, would most likely be nursing home-bound, and definitely would not be the same person that they know. In addition, he could even get worse as the swelling of the brain increase. No question, I painted a grim scenario.

After hearing my assessment, the patient’s son and family, were ready to call hospice and just make the patient comfort cares. The son told me that his father, for sure would not like to live a life with such a poor quality as I have projected. Though I told them, that the neurologist whom I consulted have not seen the patient yet, and perhaps they should wait on what he has to say.

Not long after, the neurologist came. He extensively reviewed the CT scan of the head, and he made a careful and detailed neurological examination of the patient, as he tried to evoke even obscure reflexes that I can only read in the medical textbook. After his evaluation, the neurologist, the patient’s son, and me, went in a room for a conference.

The neurologist explained that with his estimation, even though the stroke was large, since it involved the non-dominant side of the brain and mostly the frontal lobe, he believes that the patient can still have a “meaningful” recovery. In addition, since the acute stroke was a few days ago, he thinks that the swelling was on its way down, and perhaps we were already past the worst phase. He backed this with his expert knowledge of brain anatomy and function.

Thus the neurologist believed that at best, though it may take months of rehabilitation, the patient can talk – though with a funny accent, walk – but with a limp that he even demonstrated, and maybe could even live independently later on. He definitely painted a more rosy picture than the gray picture that I have painted.

Hearing the neurologist’s opinion, it was obvious we have a “slight” difference of opinion. Perhaps slight was an understatement.

After considering the neurologist’s evaluation, the son and the family changed their mind and decided to defer calling hospice and instead support the patient as much as possible, including tube feedings and all.

To be honest, I was a bit perturbed that I gave such a bleak prognosis than what the other doctor gave. Have I given up on that patient too soon? Have I killed the embers of hope prematurely? Perhaps I have become so pessimistic in my view of things. Perhaps I have seen so many prolonged sufferings and bad outcomes despite our best intentions and efforts in my ICU experience. Perhaps I was just saving the family from the heartaches of clinging to unrealistic optimism. Or perhaps I become more cynical and have lost my faith in hope.

In my defense, maybe I just see the front end and the acute catastrophic courses of patients in the ICU, and have limited exposure to the success stories of patients’ wonderful recovery after prolonged and extensive rehabilitation.

But even though I felt betrayed by my negativism, I felt relieved that I have heard a differing opinion, and perhaps gave a chance to a life that we almost gave up on too soon. Even though I felt embarrassed and almost apologetic for my opinion, I was thankful that we gave hope a chance. Everybody deserves that chance.

The following day, when I rounded on our stroke patient, he was more obtunded and unresponsive. He now have labored breathing and had to be placed on a ventilator. I then requested a repeat CT scan of the head.

The CT scan showed what I was afraid would happen: a further extension of the stroke and more swelling, displacing the structures of the brain beyond the midline and even herniating down the brainstem. This was unquestionably a grave condition, and most likely fatal. No more differing opinions.

The family decided to transition to comfort cares, and the patient expired a day later.

I did not kill hope. It died.

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Still My Beating Heart

She laid there motionless in the ICU bed. The only movement was the regular rise and fall of her chest as the ventilator blows air into her lungs. The only activity in the room was the continued bleep and tracings of the bedside monitors attached to her, indicating that she still has a blood pressure, and a heart beat, for otherwise she really appeared lifeless.

As I entered the dimly lit room, I noticed a photo on top of the counter near her bed. It was a photo of a happy family. In it was the patient and her husband, surrounded by their eight children. Yes, eight. That was kind of large family to an American standard, or perhaps anywhere else nowadays.

I appreciate families placing photos beside their loved one’s bed. Especially in our patients in the ICU as most of the time we never knew them before they got sick and deteriorated to their current condition now. Somehow the photos gave us an insight to the life, a snapshot if you will, of whom we are taking care of. It humanizes them, at least to us. That they were someone’s mother, or wife, or friend. Or they were once a decorated soldier (as their uniform indicate), or a coach, or a teacher. That they are not mere blob of a body hooked to life-sustaining machines.

My patient was in her early fifties. I learned that all the eight children that she have, were all adopted. They ranged from sixteen to eight years of age. That tells me what kind of person I am caring for. A woman with such an enormous heart, with overflowing love to adopt eight kids, and call them her own.

Unfortunately, it was also her heart, I am talking now of her anatomic organ, that caused her illness.

Few years ago, she needed an open heart surgery to replace one of her heart’s valve, the aortic valve, which was diseased. The aortic valve is the one that opens and closes as the heart pumps out blood from the left ventricle (the main pump chamber) into the aorta (the big artery that distributes blood to the head and the rest of the body). Her aortic valve was replaced with an artificial mechanical valve.

A replacement mechanical valve can last for many years, in fact, a lifetime, unlike a tissue valve (usually a pig’s or a bovine’s valve) which only last an average of ten years. However, a mechanical valve increases the risk for forming blood clots, and thus the recipient of those valves requires to be on blood thinners (anti-coagulants) permanently.

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mechanical heart valve

A few months ago, our patient underwent a necessary outpatient simple surgical procedure that required her anticoagulation to be interrupted briefly. Sadly to say, this caused a catastrophic event. She developed blood clots that led to a very extensive stroke. Our patient really never recovered completely after that. In spite of all the efforts and rehabilitation, she never walked again, she never spoke again, nor she did much of anything anymore.

I can just imagine the heartache to her husband and their kids to see her in that state of helplessness. But their family tried to move on.

And now this happened. She developed a severe bacterial infection that spread into her blood system. She went into septic shock. This infection caused a bacterial nidus to settle in her mechanical heart valve, a condition called septic endocarditis. The problem with a prosthetic metal valve affected with an infection is, it cannot be treated with antibiotics alone, it needed to be removed or replaced surgically. A surgery that she perhaps cannot survive through, nor can she survive without.

As I met with her husband and discussed her grave situation, he softly told me, with tears rolling down his cheeks, that the most loving and humane way of caring for her, was to let her go. I cannot agree with him more. And as we end our talk, he was not the only grown up man with tears in his eyes, for I did too.

The children came one by one to her room and they said their final goodbye. It was so painful to watch. After that, the life support was taken off. All the medication drips, except for medication to keep her comfortable, were shut off.

After several quiet moments of waiting that seemed like an eternity, her beating heart……the heart that was large enough to adopt such a large family, and the heart with such infectious love to share, and the heart that beat for others…..became still. Very still.