journeying to a time of death
Katherine Bakke
Her belly hurt, and I didn’t know why.
“Ms. Murray” had been admitted to the ICU two weeks prior with influenza and pneumonia. She was so sick and septic, that she ultimately required 20 liters of fluid, steroids, pressors, antibiotics. But somehow she had made it through. We had diuresed her of all that fluid, and she had extubated. But now, a day after coming off the ventilator, she winced when I pushed on her belly. And I didn’t know why.
On rounds that morning, I mentioned this to the attending, who examined her and agreed. We got an x-ray, which didn’t show much, and then proceeded to get a CT scan, which revealed a large rectus sheath hematoma, and blood in her retroperitoneum. We started giving her blood, switching our plan from convalescing her from her pneumonia to treating her for hemorrhagic shock. The turn of events was unbelievable.
We had hemmed and hawed all morning about whether of not we should get an angiogram. We needed to know where she was bleeding, because we needed an intervention to stop it. But the contrast, we knew, would ruin her kidneys. We decided to go for it anyway.
I traveled down to CT scan with her, and she had responded well to the blood that she was mentating enough to hum church songs to herself. As we positioned her in the scanner, and hooked her IV up to the contrast that would destroy her kidneys, I said to her, “Ms. Murray, I’m worried about you.”
She looked at me, the most serene smile on her face. She said, “Oh honey, don’t you worry about me.” She had the most delightful southern accent. This was the first and only time we were able to speak to one another.
The CT scan didn’t show a blush. So we had killed her kidneys, and were still contending with her bleeding. The next morning I arrived to the ICU to find her intubated and on triple pressors once again.
The first thing the attending did was come up to me and say, “I need you to make her family make her DNR.”
I need you to make her family make her DNR.
It was a task. It was a get. It was a negotiation. And I knew by now that my worth as a resident lay in my ability to get things done.
I went into her room to try to tell her daughters about what was happening, to complete the task I had been given by the attending. I could only get so far.
“She’s very sick. The blood is helping, but the bleeding hasn’t stopped. Her kidneys don’t work. She needs dialysis but we can’t do it now with all the pressors she’s on. We need you… we need you… we need you…”
I couldn’t complete the sentence. All I was doing was trying not to cry because all I could think about was how I should be able to do something for this woman. I should be able to stop her bleeding. I should be able to give her enough blood to wean her pressors to get her on dialysis to treat her hyperkalemia to give her more blood to be able to stop her bleeding. I should be able to do these things because I went to medical school and I’m her doctor and her family is staring at me like you have failed you have to do something you have to save her why won’t you save her.
A senior resident took over the conversation for me. What I remember most from that day was how out of control I felt, how impotent against the hemorrhage, the lab calling me and reminding me hourly that she was dying: “I have a critical for you: potassium 7, hemoglobin 6, lactate 14. What’s your name?”
Since that time, I’ve been terrified of my patients dying, and avoided difficult conversations with their families. Ironically, I studied this during my master’s program, I wrote and published a paper on it, I have read every single article that’s probably ever been published on how to train surgeons on how to talk about end of life decisions, so I thought I should be good at it, but I’m actual terrible. It always feels like a negotiation, presenting facts like they should be a substitute for feelings, demanding rationality in a situation that is highly irrational, a conversation devoid of hope.
I had never pronounced a patient dead until last month, which is pretty remarkable considering I’ve been a doctor for nearly three years. I was taking care of an elderly man with COVID and something catastrophic had happened to his body that we didn’t understand because we don’t understand this virus. His liver wasn’t working, his blood was clotting wrong, he was on three pressors, his kidneys needed dialysis.
I had seen this before and I had learned that this was not recoverable. I knew I would have to call his family and negotiate. I picked up the phone to reach his granddaughter. “He is very sick, his liver is not working properly, he cannot process the lactate. We are doing everything we can, but I’m worried he won’t get better.”
“We want to give him 72 hours. That’s what they said yesterday, that we would try dialysis for 72 hours.”
“I’m not sure he has 72 hours.”
“We want him to fight, he is strong.” I could tell she felt defensive. The whole conversation felt antagonistic.
“Ok,” I said defeated. “I’ll call you later with the next lab results.”
That afternoon, the family had called the unit to request that a priest come by to administer sacrament of the sick. His nurse and I were both Catholic, and we looked at each other as the priest stood outside his room peering in, and we asked each other, “Should we pray with him?”
It was possibly one of the more conspicuous things I’ve done in the hospital, praying with the priest in the hallway of a hectic ICU, because everyone looked at us as we bowed our heads and clasped our hands and said the Our Father. Strangely, though, I realized that in doing this, I had done everything—everything–for this patient. I felt comforted.
I called his granddaughter before I went home. There was no good news, the labs were getting worse.
“By the way, the priest came by this afternoon. The nurse and I prayed together with the priest. I wanted you to know that.”
When I said this, the tone of the conversation shifted. It was no longer a debate, with different sides arguing different things. Suddenly, it was as if she knew that I was on her side, that I wanted what she wanted, which was for her grandfather to live.
“Thank you for doing that,” she said. “Our family will be relieved to know the priest came by.”
“I’ll call you in the morning,” I said. I signed out to the night team that this man was going to die, it was just a matter of when.
The next morning, he was still alive, which I believe is a testament to the power of our medicines and machines. But he had made no progress, only worsened. His blood pressure started to dip on the pressors, which I took as a sign to mean that he was close to death.
I called his granddaughter again. “He survived the night. But the medicines are starting to lose their effect. I’m worried he will die this afternoon.”
“Ok,” she said. “My family is all going to get together at my brother’s house and going to make a decision.”
A few hours later, they called. They had decided to withdraw care. So I gowned up, slipped my phone into a plastic biohazard bag, and set it by the patient’s ear, and let them each take turns to say goodbye. We disconnected him from the ventilator, and stopped the pressors. I watched the color rush out of his face, his breathing slow and cease, his heart stop. He died at 12:27 that afternoon.
I spent the next two hours completing the impossibly complicated discharge paperwork that it takes to get a dead person out of the hospital. I called the granddaughter once last time to confirm the name of the funeral home she had chosen for him.
And then she said, “Thank you for all that you have done. This would have been so much harder if you hadn’t been his doctor. This must be so hard for you.”
I smiled a little, because it was hard, and because it was a strange thing to be comforted by a family whose grandfather they had just lost.
“It’s hard for everyone,” I said. “You clearly have a wonderful family. Thank you for helping me to get to know your grandfather. It’s a privilege to have taken care of him.”
Katherine Bakke, MD is a third-year general surgery resident, a self-confessing “family medicine doctor who wants to operate.” She studied religion as an undergraduate, served as an Americorps volunteer in Harlem, NYC, and obtained a Masters’ of Public Health with a focus in social and behavioral sciences. She has kept a journal since childhood, and finds her work in the hospital, and her habit of writing, to be a true, joint, and liberating praxis.
