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Dying With Dignity

Dr. Rob wrote a touching blog post today about death and dying.  He contrasts two deaths – one in which the family members were excluded from the room as physicians deliberated about the patient’s heart rhythm (while she was dying), and another one in which a patient was surrounded by family members who sang a hymn and held him in their arms as he passed.

Although the ultimate mortality rate of individuals has been 100% throughout history, physicians are trained to fight death at all costs.  When you think about it – we must be the most optimistic profession on the face of the planet.  Who else would leap headlong into a battle where others have had a 100% failure rate since the beginning of time?

Instead of thinking of medicine as a means to defeat death, I think we should consider it a tool to celebrate life.  Adding life to years is so much more important than adding years to life – and yet we often don’t behave as if we believe that.  Unfortunately in my experience, death has not been handled well in hospitals.  For every hymn singing departure, there must be 100 cold, lonely, clinical deaths surrounded by a crash cart, CPR and shouting.

I remember my first death as a code team leader in the ER.  An obese, elderly man was brought in on a stretcher by EMS to the trauma bay.  They were administering CPR and using a bag valve mask to ventilate his lungs.  He skin was blueish and there was absolutely no movement in his lifeless body.  His eyes were glassy, there was no rhythm on the heart monitor… I knew he was long gone.  The attending asked if I’d like to practice placing a central line on him, or if I’d like to intubate him to get further experience with the procedure.  She saw that I was hesitant and she responded, “This is a teaching hospital.  It is expected that residents learn how to do procedures on patients.  You should take this opportunity to practice, since it won’t hurt him and it’s part of the code protocol.”

As I looked down at the man I overheard that his family had arrived and was awaiting news in the waiting area.   I sighed and closed his eyes with my gloved hand, gently moving his hair off his forehead.   I looked up and told the attending that I was sorry but I couldn’t justify “practicing” on the man while his family waited for news.  I took off my gloves, quietly asked the nurses to please prepare the body for viewing, and walked with my head hung to the private waiting room.

The family scanned my face intensely – they could see immediately that their fears were confirmed by my expression.  I sat down very close to them and told them that their loved one had died prior to arrival in the Emergency Department, and that he did not appear to have suffered.  I told them that we did all we could to revive him, but that there wasn’t any hint of recovery at any point.  I explained that his death was quick and likely painless – probably due to a massive heart attack.  I told them that they could see him when they were ready, and that I believed that he had passed away with dignity.  They burst into tears and thanked me for being with him at the end.  I hugged his wife and walked the family to his bedside and closed the curtains around them so they could say goodbye in their own way.  I hoped that they felt some warmth on that very dark night.  “Doing nothing” was the best I could do.This post originally appeared on Dr. Val’s blog at

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3 Responses to “Dying With Dignity”

  1. rlbates says:

    Dr Val,  you did so much more than “nothing”!

  2. Number One Dinosaur says:

    You didn’t “do nothing.” You were present — emotionally as well as physically — for the family when they most needed someone. You “witnessed”; the death, as well as the meaning of the death, which was more than the attending did.

    You have every right to be proud of your conduct that night.

  3. KellyClose says:

    thanks so much for this insider view. i hope your instincts are shared by many doctors in training. 

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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