Thanks For Death

"Code Blue, 4 South. Code Blue, 4 South."

I hear the overhead announcement and I'm on my way even before the code pager erupts into a shrill scream followed by the detached mechanical voice announcing the same words. Someone's dead and it's my job to go see if we can get them back. It's 4am and in 3 weeks, I haven't been called to a code.

When I get there, it's evident that we're not going to beat death tonight. CPR is in progress - the patient is elderly and it's not just his hair that's gray. I walk in, take a look. There's no pulse, he's not breathing. I peel back the eyelids and his pupils stare back at me wide and glazed. His skin is ashen and mottling has begun. The torso is still warm - but his hands and feet are cool.

"When was the last time anyone saw him?" I ask.

The answer isn't good: "45mins ago."

The nurses look at me expectantly for direction. One of them is continuing with the CPR - obligation replacing common sense. We all know it's futile, but I have to say so. I want to call it off - but I feel obliged in any case to get at least confirmation of a rhythm - so we hook the leads up to the machine to see a flat line trace its way across the screen.

"Check another lead."

Another flat line - asystole. This isn't a heart that will be easy to restart. And my patient is old and worn down, a frail body at the best of times.

"Call it off," I say.

So they stop the CPR. The record will show that the code lasted just 10 minutes, that I didn't give him medications, put an IV in him, intubate him or shock him. I wonder if that's a bad thing, but experience and life in the ER has taught me that sometimes it's better to preserve human dignity than to look good on paper. Sometimes.

People watch codes on TV and they imagine this is a glorious, glamorous type of thing to perform on someone. They imagine that the handsome patient will suddenly gasp for breath, will miraculously recover and sit up and speak. They imagine all sorts of things but seldom do they realise what it is that really happens in a code.

We strip you in a code - there's no place for dignity.

We often break your ribs in a code - there's nothing quite like the feeling of compressing a broken chest.

We'll shove a large tube down your windpipe.

We hook you up to leads and - sometimes but not always - we'll charge our machine up to 360J and shock you.

We'll do it over and over until one of us decides to stop or you come back.

When you come back, you won't be conscious.
You won't sit up and talk.
You won't do anything at all actually.

We'll cart you off to the ICU where you'll be on life support.
Sometimes you won't come off it at all.
Sometimes you'll be brain dead - that's if you're lucky.

Other times you'll be brain damaged.
Or your lungs won't function any more and you'll need a machine to breathe forever, so we'll give you a tracheostomy to breathe through, but will take away your voice.

And sometimes - just sometimes, rarely, once every so often - we'll cheat death. We'll bring you back and you'll be just fine. You'll live to tell the tale. Our successes perpetuate the cycle of false beliefs about codes. You'll tell your most decrepit friends how you survived - and they'll come in demanding we "do everything" for them even when it seems utterly futile.

But not tonight. Tonight I sit with the patient's wife and I explain to her that we have done none of these things. I explain that I have asked everyone to stop the code. I explain that we have not stripped him, or broken his ribs, or shoved tubes down him. I explain that we've let him die in dignity. I explain that he was already dead for a while when we started. I explain all these things and I hold her hand and let her cry.

And when she's done crying, she thanks me.

When I leave at last, it's past 5am and I can't sleep. So I'm writing this. I can get used to codes. I can get used to death. But 3yrs later, I still can't get used to being thanked by families. Because they always do. They always thank me no matter how bad the news is. No matter that I will always be the doctor they remember as the person who brought them the news that destroyed their lives as they knew it. They always will thank me.

I have been thanked for telling thirty year old women they have cancer that has spread everywhere. Thanked for telling a mother her child is dead. Thanked by widows after breaking the news of their husbands' deaths. Thanked over and over.

I can get used to death. But never to the thanks. And I want to be the doctor they remember as saving lives. Not destroying their worlds with a few simple words.

But I swallow my protests. They need to thank me. So I let them. And then I wander back to my room in this hospital where death is ever-near and I swallow what grief still wells up in me and I get on with the job. And life goes on.