Far nearer to death than life, yet her eyes, pale blue like a set of china cups my mother once had, were suffused with light, and her eyes showed life and that was all that remained. They were mostly drowsy now and half-opened: her body was a discarded husk, wracked by strokes, and further insulted by dementia. She recognized no one and spoke not at all. She had decubitus ulcers over each hip, deep and foul, eating into the underlying tissue; she could not lay on her back: the contractures from her strokes had pushed her frail legs up to her chest. She lay in a fetal position, at the end of life, but she had no cushion of amniotic fluid, only a thin emergency department mattress and a few pillows. She was incontinent of stool and urine, and when the ambulance off-loaded her onto the emergency stretcher, her adult brief was heavy and soaked. The stench of piss, strong and rank with (I suspected) white cells and bacteria, was overwhelming.
She could not swallow, and this, perhaps, was the ultimate source of her problems. She had a feeding tube inserted directly into her stomach, through which she was nourished by a sophisticated version of Ensure. Patients with feeding tubes are supposed to be propped upright after feeding to avoid any regurgitation of the feed up the esophagus and into the lungs. At some point or place, this was not done; maybe her contractures made it difficult to position her, or maybe she vomited anyway. At any rate, she aspirated, and a good deal of her stomach contents passed into her lungs, in turn prompting a pneumonia.
In short: she was demented, stroked, hopelessly contracted, ulcerated (and along with any number of nontrivial comorbidities, like coronary artery disease and diabetes) — a patient with objectively no quality of life from a nursing home notorious for providing poor patient care. She was febrile, hypotensive, dehydrated and probably septic. And after 89 years, 6 months, and twelve days and maybe 3 1/2 billion heart beats, she was dying at last.
According to the nursing home notes sent with her, she was a full code.
Full code means, if a patient has a cardiac or respiratory arrest, we are ethically and legally obliged to perform life-saving measures. We go full tilt. Rib cracking compressions, intubation, defibrillation, various push medications and infusions to prolong life, in this case, for a few hours or days.
We cleaned her up and assessed her, started an IV and the antibiotics, and after a while, her daughter arrived looking older, I thought, than the date that would show on her birth certificate. She sat by her mother, and even so, she looked lonely, worried, unhappy. She stroked her mother’s hair, all the time looking for those eyes, now closed.
I asked her about her mothers wishes, and what would she would want if she knew she was dying. I asked her about what she understood about resuscitation, and discussed with her all the treatment options. Finally, I asked what she wanted us to do in case her mother’s heart stopped.
She seemed puzzled by the question. She considered, and then said with unintentional humour, “Maybe a little shock or two to help her.”
I suppressed a smile, tried another tack. I asked her about her mother’s life. Silence for a moment, then she told me about her mother, who did “nothing important” but carried the burden of a drunken, abusive husband for forty-five years, until he mercifully died in 1988; after which her mother seemed to bloom for a season of five or six years, until the first stroke, and then a second left her nearly completely debilitated.
Was there conciousness at all behind those blue eyes? I wondered. What would she want?
I went through all the treatment options again, while she held her mother’s hand. I talked about quality of life, and futility and dignity.
“She wasn’t important,” the daughter repeated. “She never did anything exciting. I’m all that’s left of her.” She peered anxiously at her mother’s face. She would not make eye contact with me. “She has me and I have her.”
I got it, at last: she wasn’t ready to have the conversation.
I thanked her for her time and assured her her wishes would be respected.
I thought: full code granted her mother importance, as if we in attending to her death we would give life significance. Full code meant her life had value and meaning, after a life of seeming meaninglessness. And at the end, all they both had left was each other.
I flipped through the chart to the nursing notes, and set pen to paper. I started to write: “Full code. . .”