There was absolutely no way around it. She was dying. I gave her a few hours at best, with maximum pedal to the metal intensive medical care. Paramedics had picked up this homeless woman after she collapsed under a bridge in Oakland, Calif. Her heart had completely stopped. She had died under that bridge. But the paramedics had somehow pulled her back, with a jump-start to her heart. And then brought her right to my service in the intensive care unit.

She had no known family, and the police were trying to track down anybody who could speak for her. No luck so far, the social worker told me.

She was emaciated, with an incongruously large, round belly, hard as a basketball. Her hair was knotted and tufted, her lips cracked and dry around the breathing tube. By the time I saw her, she had already been treated by many health care professionals. They had done CT scans, inserted large catheters into larger veins, and started various drips.

Now it was my turn to take over.

The situation was dismal. This 51-year-old woman had all of the dreaded and irreversible complications that come with chronic alcoholism. Crucial organs were failing. Her liver, the organ that produces the sugars needed for life as well as for clotting and detoxifying the blood, was almost completely shut down. Now a tight nub of scar tissue, it functioned like a clogged sieve, preventing fluid from returning to the heart. And so liters of it pooled in her abdomen, giving her the look of a woman in her final days of pregnancy. Her pancreas was in tatters from repeated bouts of alcohol-induced pancreatitis over the years. Her kidneys had been limping along for months on the verge of failure, and had now completely shut down.

And on top of all this, she was in profound shock, her blood pressure having sunk to the lowest readings attainable, despite being “maxed out” on blood pressure support medications. Shock can have a few different causes. And we medical detectives, like those on the TV show “House,” are driven to narrow down the possibilities until we arrive at an answer. We order numerous tests, many of which are risky and painful. For dying patients, these tests often don’t provide helpful information anyway — they rarely change the outcome, and may even kill the patient.

And there was no doubt this woman was dying.

As if this scenario weren’t awful enough, her brain was profoundly and irreversibly damaged. The CT scan of her head painted a grim picture. The cells of her cerebral cortex, those which give us our personhood, consciousness, cognition and independence, were swollen and dying, and there was no chance of reversing it. She would never again wake up.

But it’s not that simple for an I.C.U. doctor. Our training urges us on, even when it is clear our patient is dying, and especially if there is no family to consent to putting the brakes on.  (…) Read Full Article Here

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