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Overview


Intensive Care
is an affecting view from the trenches, a seasoned doctor's minute-by-minute and day-by-day account of life in the Intensive Care Unit (ICU) of a major inner-city hospital, San Francisco General. John F. Murray, for many years Chief of the Pulmonary and Critical Care Division of the hospital and a Professor at the University of California, San Francisco, takes readers on his daily ward rounds, introducing them to the desperately ill patients he treats as well as to the young physicians and medical students who accompany him. Writing with compassion and knowledge accumulated over a long career, Murray presents the true stories of patients who show up with myriad disorders: asthma, cardiac failure, gastrointestinal diseases, complications due to AIDS, the effects of drug and alcohol abuse, emphysema. Readers will come away from this book with a comprehensive understanding of what an ICU is, what it does, who gets admitted, and how doctors and nurses make decisions concerning life-threatening medical problems.


Intensive care for critically ill patients is a new but well-established and growing branch of medicine. Estimates suggest that 15 to 20 percent of all hospitalized patients in the United States are treated in an intensive or coronary care unit during each hospital stay, so there is a real possibility that the reader will either be admitted to an ICU himself or herself or knows someone who will be. Murray not only offers a real-time account of the diagnosis, treatment, and progress of his patients over the course of one month but also conveys a wealth of information about various diseases and medical procedures in succinct and easy-to-understand terms.
In addition, he elaborates on ethical dilemmas that he confronts on an almost daily basis: the extent of patient autonomy, the denial of ICU care, the withdrawal of life support, and physician-assisted suicide.

Murray concludes that ICUs are doing their job, but they could be even better, cheaper, and—most important—more humane. His chronicle brings substance to a world known to most of us only through the fiction of television.

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Editorial Reviews

San Francisco Chronicle Book Review
Dr. Murray is an evenhanded guide to the real world of intensive care medicine. His book is informative, a necessary counterweight to the medical fiction of popular entertainment. It may not be something to read for entertainment, but it is important to read if we are to know what crisis medicine can and cannot do for us.
New York Review of Books
It is in the daily detail of an ICU at work that Murray wonderfully depicts a place of function and dysfunction…
Publishers Weekly - Publisher's Weekly
"What this book is about," explains Murray (professor emeritus at U.C.-San Francisco) in his prologue to this journal, is "how doctors and nurses make decisions concerning... urgent medical problems." As an attending physician on the Intensive Care Unit at San Francisco General Hospital--a unit that sees a large number of poor patients--Murray believes the processes guiding those decisions deserve strenuous review. In 28 chapters he does just that: using a daily journal format, he leads readers through 28 typical days on the ICU, describing the patients who come through the unit's doors and reproducing the medical notes he writes in their files. It is not long before his point becomes clear: although he believes that an ICU should give all patients care that will restore them to a good life regardless of why they came to the unit (including alcohol or drug abuse), he is convinced that patients who will die within a period of days or weeks should be denied ICU admission. It's a controversial point, but one that Murray defends with case examples and analysis. According to the author, patients who are unable to make decisions and have not instructed their families about end-of-life care are sometimes kept in the ICU when they are close to death, painfully prolonging their dying. Although the dry presentation of chart notes is occasionally either repetitive or confusing, Murray's narrative indicates that he is a dedicated physician who debates with himself about the patient care decisions he has to make on a daily basis. His book is likely to spark a heated debate. (May) Copyright 2000 Cahners Business Information.|
Library Journal
Murray (medicine, Univ. of California, San Francisco; coeditor of The Textbook of Respiratory Medicine) takes the reader on his daily rounds at the intensive care unit (ICU) of the San Francisco General Hospital. Over the course of a month, 60 critically ill patients are treated there under his supervision. We discover how the best of modern medical technology is applied, with expert efficiency, compassion, and at colossal financial cost, to the treatment of the patients in this major inner-city hospital ICU. Between realistic scenes of bedside medical diagnoses and analyses, we also encounter the ethical dilemmas confronting today's medical establishment and society. Recommended for its naturalistic picture of inner-city hospital medicine.--James Swanton, Harlem Hosp. Lib., New York Copyright 2000 Cahners Business Information.\
Booknews
A day-by-day, minute-by-minute account of life in the intensive care unit of a major inner-city hospital, San Francisco General. Murray (medicine, U. of California-San Francisco) escorts readers on his daily ward rounds, introducing them to the desperately ill patients and to the young physicians and medical students who accompany him. They should come away with an understanding of how such wards work on the scientific, mechanical, political, social, and emotional levels. Annotation c. Book News, Inc., Portland, OR (booknews.com)
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Product Details

  • ISBN-13: 9780520234673
  • Publisher: University of California Press
  • Publication date: 7/1/2002
  • Edition description: New Edition
  • Edition number: 1
  • Pages: 310
  • Product dimensions: 6.00 (w) x 9.00 (h) x 0.75 (d)

Meet the Author

John F. Murray is Professor Emeritus of Medicine at the University of California, San Francisco, where he was Chief of the Pulmonary and Critical Care Division from 1966 to 1989. He is coeditor of the Textbook of Respiratory Medicine (third edition forthcoming in 2000).

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Read an Excerpt




Chapter One


DAY 1
Thursday


I walked onto the ICU a little before 8:00 A.M. to find three third-year medical residents—Dr. Ella Andrews, Dr. James Shotinger, and Dr. Ian Trent-Johnson—waiting for me. Each had a big smile. They had arrived early to familiarize themselves with our patients and already knew a lot about them. Their smiles were not only welcoming but inquiring. We were all going to spend the next four weeks together, and they were curious to see how well I would help them handle the formidable problems that lay ahead of us: would I be an aid or an obstacle, a rabid interventionist or a do-nothing conservative, a stickler or a laissez-faire leader? Could I teach? Now in the last year of medical residency, they had learned that much of their training in internal medicine is subject to variations in attending physicians' style and competence.

    While they were wondering about me, I was scrutinizing them. Depending on their clinical abilities and willingness to work hard, the four weeks I would spend in the units and my level of anxiety during our rotation together would be either manageable or exceedingly uncomfortable. I would be depending on them, and on a number of other personnel as well, to carry out the plans we had agreed on during rounds, to show good judgment in dealing with new patients and with matters we had not discussed, and to contact me if something came up that they were uncertain about. Each patient admitted to SFGH with a medical problem is assigned to the care of a housestaff team; the leader of the team is a second-year residentwho supervises two first-year residents and, usually, one or two medical students. The members of this team follow their patients throughout their stay in the hospital, wherever they go, including the ICU, where there is another layer of medical supervision, the third-year residents who work with me. Our resident on call today, attractive and talkative Ella Andrews, moved quickly to the nearest phone to page the first of the teams who would come to tell us about their new patient. That is when our month in the ICU begins.


* * *


Her family had decided that Jisoo Hong should die, but she was not allowed to. Mrs. Hong is a seventy-six-year-old Korean-speaking woman with multiple chronic medical problems, whose mind is lost forever behind a shroud of dementia. Her mental blankness is presumably the result of numerous strokes; she has no idea who or where she is, she cannot talk or communicate in any fashion, and she is totally blind. She also has serious heart disease, which required surgical implantation of an electronic pacemaker to sustain a regular heartbeat, and she suffers from diabetes mellitus ("sugar" diabetes), which necessitates insulin every day. As the admitting first-year resident tells us, because of the severity and irreversibility of her problems, the family decided several months ago that if a medical catastrophe were to occur—and one was inevitable—she should be allowed to die peacefully and should not be resuscitated if her heart stopped. Nor should she have a painful tube inserted through her mouth or nose and fastened in her windpipe—a procedure called intubation that enables a ventilator to assist someone's breathing.


Intubation is a common and crucial ICU maneuver. But in people who are awake, intubation is extremely disagreeable and must be performed using local anesthetics to block the powerful cough-and-gag reflexes triggered by the procedure. Imagine having a one-foot-long plastic tube thicker than your index finger scrape along the back of your throat, force its way between your vocal cords, and finally be fixed within your windpipe by a balloon inflated near the tip. Painful sensations inevitably return when the anesthesia wears off and the reflexes wake up. When patients cannot breathe by themselves or cough to prevent food and liquids from entering their windpipes, intubation must be done to save their lives; but just as soon as it is safe, we take the tube out because most patients fear and hate it. Many of the decisions we have to make are dictated by this dreaded but often necessary tube.


Incubating a patient like Mrs. Hong is inhumane unless there are clinical rewards to offset the torment and numerous potential complications. We agree completely with her own family's and physician's decision not to intubate her. But here she is—intubated!

    At home two days before, Mrs. Hong had trouble breathing during the night. Yesterday morning she developed a fever, and later in the day her unmarried niece, who has devoted the last five years to caring for her aunt, finally panicked and called 911. The ambulance crew responded quickly and found Mrs. Hong laboring to breathe, with frothy secretions gurgling in her throat, a sign Hippocrates, the Father of Medicine, recognized more than two thousand years ago and called the "death rattle. "But the paramedics cleaned her air passages with suction and brought Mrs. Hong to SFGH, where the physicians in the emergency department, in total ignorance of the previous decision not to intubate, acted on the urgent medical demands of the moment and put a tube in her windpipe. Then they sent her to us in the ICU for machine-supported breathing. They also began antibiotic treatment for pneumonia—dearly the cause of her respiratory distress.

    By the time I see her this morning, all this critical background information has been uncovered. The first-year resident who called her private physician, Dr. Ira Constant, in the middle of the night, reported sheepishly, "He shrieked at me."

    "She's what? Incubated! You guys are out of your minds," Dr. Constant had shouted. "Do you know how many hours I spent persuading her family she should NOT be incubated? Now you've screwed it all up." Dr. Constant's distress is justified. After his considerable efforts to spare Mrs. Hong the misery of incubation, that is exactly what has been inflicted on her.


Pneumonia—what Sir William Osler, one of the demigods of early twentieth-century medicine, called "the old person's friend"—was trying to put an easy end to a life that had no positive quality except in the mind of her niece, a reclusive Woman in her fifties who was totally absorbed in caring for her aunt and could not allow her to die quietly at home—even though the legally responsible members of the family had decided that was the best possible course. The niece called the paramedical personnel, who did what they are trained to do expertly: they saved her aunt's life. So did the physicians in the emergency service. Everything unfolds fast in these situations, and there is little opportunity to derail the process. Dr. Constant is right. We had screwed it up, albeit inadvertently.

    In 1991 California instituted a system for staving off inadvisable resuscitations, including intubation such as Jisoo Hong had, or efforts to revive an impotent heart, before patients arrive at the hospital and their medical records become available. A similar mechanism had long existed for patients already hospitalized. Together, patients or their surrogates and physicians can fill out and sign a special prehospital Do Not Resuscitate (DNR) form that orders emergency medical service (EMS) personnel to forego resuscitation attempts if the patient's heart stops or breathing ceases. But even this simple process does not always work: many physicians—like Dr. Constant, as it turned out—do not know about it, and even if the form is filled out, it has to be shown to the right person in time to prevent or abort action. It is hard to imagine Mrs. Hong's niece waving such an order in front of the paramedics as they were suctioning her aunt's throat and windpipe. Had Mrs. Hong been wearing one of the available bracelets or neck medallions inscribed with the words "DO NOT RESUSCITATE—EMS," her niece's desire to override the family's intentions would have been thwarted. This alerting system, alas, is neither automatic nor foolproof; the bracelet or medallion must be obtained separately and paid for, after the form is completed, and then worn at all times.

    Fortunately, the treatment Mrs. Hong had received for her pneumonia had helped enough that we could begin to take her off the ventilator. That afternoon, we disconnected it and took the tube out of her windpipe, and in the evening we moved her out of the ICU and into a regular ward. At no time did she respond when we talked to her, even when she was spoken to in Korean by one of SFGH's team of masterly interpreters, who among them know virtually every language and dialect. She just moaned and writhed intermittently, and looked tortured. Five days later when we heard she had gone home with her niece, I could only shrug helplessly, without any feeling of relief, knowing what was in store for her. Some other crisis was bound to occur, and I was certain that her niece's pitiful struggles to keep Mrs. Hong alive would add more misery to an already wretched existence.


* * *


Now we visit Charlotte Atkinson, a thirty-two-year-old part-time receptionist who came to SFGH three days ago after vomiting a large amount of bright red blood. She has severe bulimia, which is characterized by a preoccupation with weight and intense guilt about episodes of perceived overeating; these, in turn, are assuaged by purging or by self-induced vomiting. Her doctors learned that her habit of making herself vomit each time she ate had begun while she was about twenty years old and training to be a champion middle-distance runner. Professional running is associated with a high risk of eating disturbances, including bulimia, and other psychiatric complications that involve pushing body and mind past normal limits. She had won several races, but after she failed to qualify for the United States Olympic Team, she stopped competitive running and began drinking, only a little at first, then more and more. She certainly does not resemble an elite athlete today, but there is no way of telling what she looked like a decade ago. Now her face is pinched, her eyes sunken, and her body withered. Her arms are no bigger around than the bones within them, and her knees look uncommonly huge in the middle of her spindly legs.

    She had told the admitting resident that she had received psychiatric care, but she refuses to give us details about her family and social background or other aspects of her life that might provide insight into her condition. Whatever her tragedies, she keeps them to herself, and no visitors have come in whom we might ask for information about her. She insists on being called Charlotte rather than Ms. Atkinson, which is unusual, and I wonder if she has entered the hospital using a phony name, believing that hospitalization reflects personal shame rather than ill health.

    When she was first seen in the ICU three days ago, Charlotte's blood pressure was low from severe loss of blood; so she was given a large infusion of fluid through one of her veins and then a transfusion of two units of concentrated red blood cells. But because of the large volume of fluids that had to be administered intravenously to keep her blood pressure at a safe level, plus the markedly decreased amount of protein in her bloodstream due to her malnutrition, some of the fluid had overflowed from the blood vessels in her lungs into the tiny neighboring air sacs and swamped them, a common condition in the ICU called "pulmonary edema." This is a grave complication because it impairs breathing and the transfer of oxygen from the lungs into the bloodstream. The patient can drown in her own fluids. ICU doctors frequently cause or worsen pulmonary edema by giving too much blood, plasma, or other fluids intravenously.

    Because of the pulmonary edema, we had to postpone an internal examination—an "endoscopy"—of the organs in her upper gastrointestinal tract. Endoscopy is done by passing a yard-long, snakelike fiberoptic instrument, an endoscope, through the mouth into the organs of the upper digestive tract, the esophagus, stomach, and duodenum, one after the other, and displaying the image of the interior of those organs on a television monitor. The procedure was carried out two days ago when Charlotte's lungs were less waterlogged, and it revealed eroded areas of black dead or dying tissue covering much of her esophagus. No source of bleeding was discovered. The ulceration was so severe and extensive that the endoscopist first thought that she must have swallowed lye or some other corrosive chemical. When the sedation wore off and she could talk, he asked her directly if she had taken anything. "No, no I didn't, "she said in a soft but emphatic voice. "Nothing like that."

    Everything seemed to settle down, and she had been transferred out of the unit. But suddenly, about two hours ago, blood began to erupt once again from her mouth, and back she came. When we arrive at her bedside, she is receiving her third unit of blood, and two more have been ordered. Fortunately, the repeat fiberoptic endoscopy is just starting. We all gather around the television screen to watch. Charlotte's charred and ulcerated esophagus is truly exceptional but does not appear to have changed from the day before yesterday. As before, we cannot see any site of active bleeding. This time, however, her stomach contains at least a quart of partially clotted blood. Because she is continuing to bleed, I am compelled to ask the surgeons to see Ms. Atkinson; so I tell the resident to call them. Sometimes an emergency operation is the only way to stop relentless hemorrhage.


Specialists in internal medicine interact with their colleagues in surgery all the time; we have a necessary and highly beneficial partnership. Each time we meet, though, internists tend to become a little edgy. Surgeons routinely perform technical feats no internist would ever conceive of undertaking, and they bring these brilliant skills with them when they consult on a patient. But they often bring their giant egos and short fuses as well. A surgeon friend of mine has characterized his confreres as "Often wrong, but never in doubt." By contrast, the call to arms for internists is "Don't just do something, stand there." It is undoubtedly good for the profession that it includes men and women of instant action as well as those of prolonged reflection; but when these polar temperaments meet at the bedside of a sick person, things can heat up.

    Fortunately, the deliberations over Charlotte Atkinson did not result in a hot confrontation. Because no one had ever seen an esophagus like hers before, there was no personal experience—there was not even known precedent—to guide us; moreover, it was obvious from a glance at her bony face, shriveled breasts, and skeletal extremities—signs of malnutrition that were confirmed by the results of her laboratory tests—that she was a terrible candidate for the kind of extensive surgery that would be needed. Furthermore, we could not be absolutely certain that removal of much of her esophagus would cure her bleeding because we did not know exactly where the blood was coming from. Nothing causes more dissatisfaction and chagrin than subjecting a patient to a dangerous operation for ongoing hemorrhage only to have the bleeding continue afterward.

    "Better hope she stops bleeding," the attending surgeon advised us. "We'll take her, but only if she bleeds briskly again and doesn't respond to more blood." In the back of my mind another thought emerged: was it possible that this victim of a self-destructive disorder was contributing to her own bleeding by taking anticoagulants or some other medication? I would review the results of her laboratory tests carefully with this in mind.


* * *


It is already 9:00 a.m. Thirty minutes each to review two newly admitted patients is not unusual, but today is the first of the month and every one of the seven patients in the unit is new to us. Leaving Charlotte to receive another transfusion, we go next to see Althanette Washington, a sixty-four-year-old unemployed woman, who is also suffering from a gastrointestinal hemorrhage and who is known from previous admissions to be a heavy drinker, with alcohol-induced scarring of the liver—alcoholic cirrhosis. She came to SFGH last night after vomiting material that resembled "coffee grounds" and passing stools that she described as "tarry," medical terminology she had evidently heard before, and both trademark signs of bleeding into the upper gastrointestinal tract. Fresh blood is recognizably red, but when blood remains long enough in the digestive system to become partially decomposed by juices in the stomach and intestine, it turns black. Mrs. Washington had lost enough blood to make her dizzy when she stood up, but when Dr. Quillici was questioning and examining her in the emergency department, he noticed her responses were a little off the mark and she kept drifting off to sleep. Bleeding into the gastrointestinal tract of someone with cirrhosis can cause torpor, but to make sure nothing else was amiss he ordered a computed tomographic (CT) x-ray study of her head, which was taken on her way to the ICU. Her "hematocrit," our routine measurement of the quantity of red blood cells circulating in the bloodstream, had plunged, so she was transfused a total of five units of blood last night.

    By the time we see her, the gastroenterologists have already completed the fiberoptic endoscopic examination of Mrs. Washington's esophagus, stomach, and duodenum, and this demonstrated small esophageal "varices," which, as the name implies, are dilated lumpy veins similar to varicose veins in the leg. These varices form in the esophagus and stomach of patients with chronic advanced cirrhosis. They grow in an effort to reroute the blood flow that cannot get through the distorted veins in the scarred liver but often bleed torrentially. Later, when we review the CT films of her head in the x-ray department, we see that she also has a large abnormal lump in the middle part of her brain, a serious though probably benign tumor called a meningioma. We decide to keep her in the unit for another twenty-four hours to make sure the bleeding does not recur and to allow her to wake up more fully. The neurosurgeons, who have heard about her, are already circling, eager to attack her brain tumor. "We hear you've got a meningioma in here, "says the chief resident in neurosurgery, leaning in at the door.


* * *


Next, we see the four patients who have been in the unit for several days or more. Two of them suffer from the same severe condition, long-standing lung disease of the asthma-bronchitis-emphysema type, which is also called chronic obstructive pulmonary disease. One of these patients has already been in the unit for over a month, the other for "only" a week. The long-timer, Truman Caughey, just thirty-five years old, is a former truck driver who had worked regularly until a year ago. Since then he has had many hospitalizations for respiratory failure, most of them severe enough to have required intubation. Several of his attacks seem to have been precipitated by sudden bouts of agitation that provoked wheezing and coughing. In the clinic and in the hospital, his physicians have carefully questioned him and his mother, with whom he lives and who helps take care of him, in hopes of unraveling the cause of these dramatic episodes. "Were you smoking at the time? Were cats or dogs in the room? Were there fumes or pollutants in the air?" But no trigger was ever found. Agitation can incite asthma and vice versa, and it is often problematic which comes first. Consider the intensity of the emotions that must be unleashed when you feel yourself slowly starting to smother, you realize it is probably going to get much worse, and you know you could die from it.

    When we see him for the first time this morning, Mr. Caughey has been in the ICU for nearly five weeks and has required assisted ventilation almost the entire time. He has also needed intubation three times, because each time the tube is removed his asthma flares up again and he is unable to breathe by himself. Today, he is stuporous and does not wake up during our examination. I turn to his nurse, Imelda Tuazon, a dainty woman with a round, attractive face that appears fixed in a permanent smile. Although she sometimes sounds gruff ("Not now. Can't you see I'm busy?"), she has the proverbial heart of gold and will do anything for her patients and almost anything for the residents and students. Imelda, still smiling, explains, "This is because we have to give him large and frequent doses of fentanyl and midazolam (drugs used to relieve pain and anxiety). Every time the level of sedation drops, he goes wild and begins to wheeze and buck the ventilator. You'll see for yourself; it's dangerous. There's no alternative. We have to do it."

    I meet his mother, an intelligent and concerned woman, who sits patiently by his bedside, hour after hour, though he is too sedated to know. She says, "It's obvious Truman's really sick. Please tell me the worst." When I tell her he might not make it through this hospitalization, she asks, "I smoked when he was a baby. Do you think I did it to him?" I point out that he has told his doctors that he is a heavy smoker, and that this is far more destructive to his lungs than her smoking many years ago. She tells me that she and her son have never discussed the kind of care he has already received, much less the care he wants in the future, even though he has been intubated and in ICUs many times. Like many people, they find it impossible to face the issues of pain and death, even when they are directly confronting them.


Truman Caughey has severe refractory asthma-bronchitis-emphysema, but the reason he is in the ICU is because his lungs are unable to furnish oxygen to and remove carbon dioxide from his body, a condition called "respiratory failure." Normal breathing consists of the repeated inhalation of fresh air and the uptake of oxygen into the lungs, followed by the exhalation of stale air and the elimination of carbon dioxide. Besides the lungs, respiration involves the brain, the muscles that inflate and deflate the chest, and various sensors and connecting nerves, which collectively constitute the respiratory system. Respiratory failure, a common condition in most ICUs, means that any of a multitude of abnormalities within this tightly integrated system has led to inadequate uptake of oxygen, or to insufficient elimination of carbon dioxide, or, as Mr. Caughey demonstrated, both.

    I had no doubt that Mr. Caughey's respiratory failure was caused by advanced, smoking-related, chronic obstructive pulmonary disease, but it was also obvious that the problem was considerably aggravated by his need for sedative and pain-killing drugs. These medications are among the many two-edged swords in daily use in the ICU. Patients often thrash around in their beds, struggle against the hated endotracheal tube and ventilator, and may disconnect airway tubing or tear out cannulas and catheters; heavy sedation quiets these dangerous movements and allows a breathing machine to work more efficiently. But heavy sedation also depresses the brain and takes away the normal urge to breathe spontaneously, thereby causing an ICU catch-22 by prolonging the need for intubation and machine-assisted breathing. In short, we will never be able to "extubate" or remove the endotracheal tube from Mr. Caughey and liberate him from the need for machine-assisted breathing so long as he continues to receive such large doses of sedatives. Yet there is no way to get rid of these easily. Imelda, who knows what she is talking about, has warned me.


* * *


The other patient with asthma-bronchitis-emphysema is Howard McVicker, a sixty-three-year-old man who has been in the ICU one week. He also has refractory respiratory failure because of severe underlying chronic obstructive pulmonary disease, and he too requires heavy sedation to control his recurring bouts of thrashing, gasping, and evident panic. To make matters worse, when he is restless his blood pressure climbs to alarming levels and his heart rate not only accelerates but at times becomes irregular. Jack Cramer, Mr. McVicker's nurse, who knows him well, says, "Howard's doing fine, and now's the time to lighten his sedation a little"; this is welcome news that will allow us to push forward with vigorous efforts to get him to breathe on his own. We set up a plan with Jack and the respiratory therapist to cut back the sedatives and, as Mr. McVicker gradually wakes up, to reduce the amount of support provided by the machine to the level of independence he is able to tolerate.


* * *


Next, another resident fills me in about Patrick Guzman, a forty-year-old house painter with a long history of chronic alcoholism complicated by cirrhosis. Because of his steady heavy drinking, his liver disease has been relentlessly progressive. Last week he had a brief admission to the ICU for a brisk gastrointestinal hemorrhage. This time he is dying.

    Patients with advanced cirrhosis are exceptionally fragile: they are susceptible to a host of complications, of which hemorrhage and infection are among the most common and dangerous. When either of these occurs, it often causes a backlash reaction in the liver that worsens its already compromised function. This happened to Mr. Guzman shortly after he arrived. His jaundice increased, his blood failed to clot, and he developed marked swelling of his belly and legs from retained fluid. Four days ago, he became confused and then comatose; next, his lungs began to accumulate fluid, now frank pulmonary edema, for which an endotracheal tube had to be inserted so his breathing could be assisted with a ventilator. Last night, his kidneys virtually stopped making urine.

    Today, he shows florid evidence of marked liver failure, and his blood pressure is beginning to decrease. It is clear he is close to death. We give this terrible news to his two brothers, who are by his bedside. They tell us, with disarming composure, "Pat always said he never wanted to be kept alive on machines." all agree that he should be allowed to die as comfortably as possible, which means without the endotracheal tube and ventilator.


To let Patrick Guzman die quietly is an easy decision for two reasons. Above all, there is no hope for the recovery of his destroyed liver, an indispensable organ that regulates metabolism, destroys toxins, and produces vital circulating substances. He is not a candidate for liver transplantation because he continued to drink up to the day of his hospitalization. Some transplant centers will accept steady drinkers; others, like ours, require at least six months' abstinence, and even then it is debatable if alcoholics have a prognosis that justifies this elaborate and costly procedure. Because further medical care is futile, we can legally discontinue his treatment. The judgment that additional aggressive treatment would be futile is not always so easy to make, but there is no doubt here. Not only has Mr. Guzman not responded to vigorous therapy; he has deteriorated markedly despite his being treated with all we have to offer.

    The second reason for our easy decision is provided by his brothers' telling us that Mr. Guzman has clearly stated he does not want machine-assisted breathing and that the family wants it stopped. Although verbal declarations of this sort are not binding, we are glad to hear them because they eliminate the threat of confrontation when physicians conclude that a situation is futile yet the family expects a miracle.

    Around noon, after his brothers' wives and a few cousins have arrived, the endotracheal tube is removed from his windpipe, and a morphine infusion is started to make him more comfortable. Morphine also helps by preventing the reflex gasps and agonal muscle contractions that signal fast-approaching death, which the family may interpret as hideous suffering. Relief of unendurable pain and torment is one of medicine's oldest and strongest imperatives, and morphine is ideal for this purpose; it comforts the patient directly and the family indirectly.

    After the family has gathered at file bedside, Molly Wolford, the head nurse, goes in and turns off the television screen that displays Mr. Guzman's blood pressure, heart rate, and electrocardiographic tracing. "Why are you doing that?" one of his brothers asks.

    "We don't need this information any longer," she replies; "we do better without it." But Molly does not disconnect the monitor at the central nurses' station because we must know what is going on at all times. She turns the bedside monitor off because we have learned that relatives and friends tend to pay more attention to it than to their loved one. People become obsessed watching the electrocardiographic squiggles that announce each heartbeat marching across the screen. Although the physiological nuances are undoubtedly overlooked, the deeper meaning of the electrical signals of life is hard to miss when they slow in frequency, gradually widen in appearance, and then finally stop altogether.


* * *


The last person for us to see, Constancia Noe, is barely nineteen years old and in some ways the most difficult of our seven patients. She is a small woman who has a tube in her windpipe for machine-assisted breathing; a tube in the right side of her chest to keep the lung on that side expanded; a tube that goes through her nose and stomach into her intestine for feeding; a tube in her bladder to drain and measure urine; a tube in an artery in her right wrist to measure her blood pressure and sample blood; and two tubes in forearm veins for administering fluids and medications. Even though she has lost a lot of weight and is aged in appearance, it is easy to imagine that she was once very pretty, with an almond face, dark eyes, and long black hair. Now she is barely responsive: she too has received a lot of sedation.

    Despite her youth, Mrs. Noe has a long history of serious complications related to excess alcohol and heavy use of intravenous heroin, cocaine, and other uppers and downers—medical conditions ranging from pancreatitis and episodes of bleeding from her stomach to fractured bones from falling. Then, nine months before this hospitalization, she developed Pneumocystis carinii pneumonia and was diagnosed with AIDS. Now, she has features of advanced HIV disease, despite her having been treated with all the available anti-HIV medications, none of which she has ever taken regularly.

    Although the cause of her pneumonia was promptly identified and treated, she has done poorly. When she came to us for breathing support, her right lung had collapsed from an internal rupture of a small cyst that allowed air to escape from the lung and accumulate around it. To re-expand the lung, we had to insert a large-bore tube through her rib cage into the chest cavity and connect it to a suction machine and drainage apparatus that hangs at her bedside.

    I have no choice but to continue the treatment started by her other physicians. I would like to talk to her family about her dismal prognosis, but I cannot speak frankly. To the doctors who talked to her at the beginning of this hospitalization, she made her views unmistakably clear: "I've got AIDS for a long time, but my family don't know about it, and I don't want them to know about it now. "I am quite sure she is going to die, but if she instructed us to be aggressive, we might prolong her life a few weeks and get her back on treatment. At this point, though, we cannot find out what she wants because she is too sick and sedated to tell us.


* * *


Ward rounds and x-ray rounds finally finish a little after 11:30 A.M., but the day is far from over. I will make a note in the chart of every patient, which today will probably take several hours because I have to read completely through each current record. When I make my notes, I commandeer one of the barstool-like chairs that stands just outside each of the rooms; these lofty seats allow the nurses to watch their charges through a window while entering data into a nearby computer that stores the daily reports. On this perch I have easy access to the computer for the information I need to write my notes in the patient's medical record, but I also make an easy target for anyone who wants to ask a question, get advice, or just chat. And people do, all the time.

    The position outside the patient's room also means that family and friends inside can see me, so I always go in to have a few words with whoever is there. Because all this takes extra time, I am unable to finish my notes until nearly 3:00 P.M., when I buy a sandwich in the hospital's coffee shop. I slip into my office to eat it, while returning phone calls and dealing with essentials: a typical ICU day.

    About 4:00 P.M. I go back to the units to check up on things. The respiratory therapist says, "I've made good progress in weaning Jisoo Hong from the ventilator," so I tell him to take her endotracheal tube out.

    Smiling Imelda Tuazon indicates that Charlotte Atkinson is receiving her fourth unit of blood, and "She hasn't turned a hair."

    I notice that Patrick Guzman's breathing is typically agonal, with slow and shallow gasps. I speak with one of his brothers, who has come out to see me. "I think it will be over soon. How are you holding up?"

    "The sooner the better," he mutters. "This is much harder than I thought it would be. But, listen—and my brother joins me in this—everyone here has been terrific. It makes things much easier."

    "Be sure to tell that to the nurses," I reply, "they are the ones to thank." People rarely thank us for a death.

    At 6:30 P.M., before leaving, I go back and see everyone again, this time with Ella Andrews, and I am gladdened by her voluble enthusiasm. Mrs. Hong is breathing well by herself, having been extubated. Mr. Guzman is dead, and his family has gone. I meet one of Constancia Noe's brothers and talk a little with him, though I am careful not to mention AIDS. Everything else is quiet and there are no new patients. I take off.

    I arrive home thirteen hours after I left for the hospital this morning. I start to miss my wife as I walk into our house. She went to France on business two days ago and will be gone all month. I feed our cat Walter and open a beer. It has been a long day, and I am on call tonight and for the rest of the month; I will wear my beeper everywhere I go. But at least I am home and not in the hospital, like Ella and the others, who not only have to be there but will probably be up most of the time. I'll go back to the ICU if they need me, but that doesn't happen often at night.

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Table of Contents

Prologue ix
Day 1 Thursday 1
Day 2 Friday 18
Day 3 Saturday 28
Day 4 Sunday 36
Day 5 Monday 48
Day 6 Tuesday 59
Day 7 Wednesday 68
Day 8 Thursday 79
Day 9 Friday 92
Day 10 Saturday 101
Day 11 Sunday 115
Day 12 Monday 125
Day 13 Tuesday 132
Day 14 Wednesday 141
Day 15 Thursday 151
Day 16 Friday 166
Day 17 Saturday 175
Day 18 Sunday 181
Day 19 Monday 191
Day 20Tuesday 201
Day 21 Wednesday 212
Day 22 Thursday 218
Day 23 Friday 226
Day 24 Saturday 231
Day 25 Sunday 238
Day 26 Monday 244
Day 27 Tuesday 251
Day 28 Wednesday 259
Epilogue 267
Notes 277
Acknowledgments 283
Index 285
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