Last week we had a pt who showed up as a transfer from another hospital. Long story short, he was essentially brain-dead/comatose, incredibly uremic, sacral decubs, everything pointing to a vegetable slowly wasting away. He had been that way for a long time, but his wife refused to let him go. Not interested in hospice or palliative measures, she demanded that he be dialyzed, but refused to have him become a regular “dialysis” patient. She allowed for tracheotomies, but refused BIPAP. His BUN was in the 200s. His creatinine was 9. When we saw him, he just lay there like a rag doll staring blankly through foggy corneas, his eyelids unable to fully close. He was alive, but not really.

And yet, his wife couldn’t let go. She threatened to have him transferred to a different state to have him treated if we wouldn’t dialyze him. Delaware, Atlanta, elsewhere. When we had Palliative Care speak with her, she thwarted their efforts like a seasoned pro. She must’ve gotten the run-around from other hospitals already. She demanded that we just give him some “vitamins” to make him better. She explained that she couldn’t give up, because maybe in a few months there’d be a surplus of kidneys that could be transplanted, as if that would solve everything. We wondered about her capacity to make decisions, but it would be hard to establish considering that she seemed to be a pretty smart lady. She’d cared for him for years and knew how to navigate the system, but she didn’t seem capable of any real insight to his condition. She was in denial that her husband was beyond the point of no return.

It’s cases like this that bring up the difficulties in delineating where we need to draw the line in managing all these miracles of modern medicine. We can keep peoples hearts pumping, lungs ventilating, even when a patient no longer has brain activity. We can keep a patient “alive” long enough for relatives to arrive days later.. and not be concerned about their “code status,” because that patient physiologically CANNOT code while hooked up to all those machines.

It’s frightening what we can do, and how we can blur the lines between something as concrete as life and death. And that only makes it harder to know when to let go.

(He ended up having a massive GI bleed while on our service and was transferred to the ICU. I’m not sure what’s become of him since.)