As I rushed through the hospital lobby on my way to the intensive care unit, I saw the palliative care team speaking to a young woman in a wheelchair. She was beautiful, her cheeks full and round, her mouth in a constant soft smile as she spoke. She sat regally in her chair, the red of her sweatshirt anchoring my eyes in the dim hospital lobby. She was such a vision of beauty and health that it took me a second to realize that her right leg was amputated below the knee.

One of my colleagues smiled in introduction and gestured ceremoniously to the patient. “Dr. Zitter, you remember Michelle Moore.” My mind grappled for traction. I recognized the name (which I’ve replaced with a pseudonym to protect her privacy), but her face drew a blank. “I believe that you took care of Michelle in the I.C.U. when she first came to the hospital last year.” And then it came to me: When I had known this woman, she had been covered by so many tubes and wires, I could barely make out her face.

As the treating doctor for this critically ill patient, I had been sure she would die. And I was wrong. Her very presence in the lobby felt like a reprimand.

As Nicholas Christakis describes in his book “Death Foretold,” doctors are significantly more likely to overestimate a patient’s life expectancy than to underestimate it. And not just by a little. According to a large study he conducted in 2000, theyoverestimated survival by a factor of five. In that vein, it is the rare case where I feel confident that an outcome will be bad and the patient proves me wrong.

Michelle’s heart valve had become infected from a batch of bacteria-laden heroin. These delicate valves act as a backstop for the heart, preventing blood from flowing backward. In Michelle’s case, a critical valve was caked with pus and a cabbage-like mass clung to it like a rider on a rodeo horse. The majority of blood flowed backward with every contraction of her heart, instead of toward her oxygen-starved organs, and her blood pressure was critically low.

In addition to compromising her blood flow, the heaving vegetation had been steadily showering drops of pus downstream, to any location where blood flowed. Pus had woven into her muscle fibers, her kidney, her liver, and lodged into the distal regions of her extremities. Her hands and feet were so chock-full of it that they were beginning to die. But her brain, the control center of life, was our biggest concern. The CT scan showed that it was saturated throughout with fine pustules and inflammation, severe enough in some parts to have caused bleeding into its delicate tissues. The neurologists met with the family to break the bad news that significant recovery was extremely unlikely.

I, too, spent numerous hours with her family, providing support and information, and transmitting my increasing concern that she would not recover. We were approaching the two-week mark of her hospitalization, the point at which we become concerned that continuing pressure from the breathing tube can break down the delicate tissues of the throat and airway. A solution is to sew the breathing tube directly into the neck at the level of the Adam’s apple, a procedure called a tracheostomy or trach, to more safely continue to provide support from the breathing machine.

Although the procedure itself is not significantly risky, its implications are serious. Unlike the temporary breathing tube of the first two weeks, a trach does not expire. And therefore, while it may serve as a bridge to improvement, it may also function as a tomb for one who does not improve. (…) Read Full Article Here

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