Time of Death

When I was on call two days ago, my cards fellow called me to say there was an eval in the ED and could I please go downstairs to assess the patient. The only information I had was that he was just discharged 1 hr ago after a 2-day stay s/p BiVICD upgrade, and not long after he left the hospital, he suddenly became unresponsive and his wife immediately drove him back. He arrived pulseless and in V-tach; a shock of 200J pushed him into PEA and it was only with epi that he regained his pulse. The ED residents were putting a central line in him by the time I got down, with the attending planning to initiate the "Arctic Sun" protocol, also known as hypothermic therapy. Studies have shown that if a patient's body temperature is cooled to 33 degrees Celsius for 24 hrs after a cardiac arrest, then rewarmed after 6 hrs, s/he is less likely to have long-lasting neurologic damage. I had seen this method used at the JPS ICU, and this was the first time I'd seen it done here. Once the patient got up to the CCU, they placed cooling pads on him and proceeded to lower his temperature. Then he went into another sustained run of V-tach and I, as the most senior resident in the unit, had to decide whether or not to shock the patient. This was the closest I've ever come to running a code and I was terrified (even though I didn't show it), and I told them to administer the shock. It fixed his rhythm but only temporarily; it took 150 mg of amio to get him back to his baseline A-fib. Even still, I called my fellow and asked him to come to the hospital to help me out. We ended up putting A-lines in my two patients (I got my first successful A-line that night), but they were such hard sticks that we went through 10 A-line kits before we got the lines in successfully (not joking).

The next morning (yesterday) the patient's cardiologist came in to see what had happened. He told us that the patient had a history of cardiac amyloidosis that caused him to have diastolic dysfunction and increasing episodes of V-tach (they'd attempted an AV junction ablation during his last admission but it was unsuccessful). We also learned that his ICD had shocked him twice while he was in the car, but it wasn't enough to correct his V-tach. The patient's wife stayed with him and requested that we call his PCP, who was a prominent figure in the medicine program. He later came to see the patient and spoke to the family at length about the patient's overall prognosis. It also came to light that the patient wanted to be DNR/DNI, and the family agreed that once the patient was brought out of hypothermia, if he didn't regain consciousness, then they would withdraw care.

This morning the patient continued to be unresponsive and comatose even after the Arctic Sun was turned off. The patient's PCP, gastroenterologist, and EP physician all stopped by in the morning to speak to the family and offer their condolences. When all the family members had gathered, they requested that we withdraw care as they didn't want to "draw things out." The end came pretty quickly after he was extubated and the pressors turned off. We left the room but kept an eye on the tele monitor, watching his blood pressure dip lower and lower while his heart raced in V-tach in an attempt to keep his BP up. Less than five minutes later, I was in the room pronouncing the patient dead while his family members held each other and cried.

It had been a good year since I'd had to declare anyone dead, but fortunately I remembered the steps and was able to fill out the death packet and make the necessary phone calls. *sigh* And here I'd hoped to go through this rotation without ever having to fill out a death packet. In this case, however, I'm glad that the patient had made his wishes known and that his family had honored his wishes. Too many times have I dealt with families who could only think about what THEY wanted and not what's in the patient's best interests. I have yet another patient who's comatose after a PEA code, and even though it's been two weeks his wife has YET to find his living will. She says she'll bring it tomorrow; we'll see.