No, I Won't Do It.

There's this article, by some dude from Detroit called Rivers, perhaps you've heard of it--some weirdness about "Early Goal Directed Therapy" and some "Surviving Sepsis" type thing. Anyway, the upshot is that anyone who is septic--that is, has signs of a severe, overwhelming infection--should be aggressively resuscitated with tons of fluids, invasive monitoring, antibiotics, pressors, transfusion if needed, preferably (according to the original article) with expensive, slick-looking catheters. The kinds of catheters BMW would make if they were in the medical supply business. The kinds of catheters the resident gets yelled at for breaking.

This idea has saved a lot of lives, with interventions, and also with increased screening. However, the catheters have downsides; even the Toyota versions rather than the BMW versions are invasive. There's a big needle, and a wire, and it's stuck in a big vein, usually next to an artery, just above the lung. So, bad stuff can happen, and it's not like a Swedish Massage, either.

This seventy-eight, looks ninety-eight lady is brought in from the nursing home in her bathrobe because she's 'not acting right'. Of course, she's non-verbal at baseline, and lays on her side until someone turns her. Her legs are atrophied and contractured up so they no longer straighten. Her skin is taught like parchment. She looks at nothing, just generally up; one could imagine she looks to her eventual home. She doesn't moan or wail or complain--there's not enough left, I don't think. And yet, she's a so-called 'full code'--that is, we, as the medical establishment, should do everything to save her life, including push on her chest and break her ribs to force blood up to her damaged brain, put a tube in her throat, and stick her with needles.

Well, I'm sorry, family that can't accept the loss of your loved one that happened years ago with the first stroke, I'm not doing it.

I'm not going to lay her in a position where her head slopes down to make the vein bigger, clean her neck, and stick a long hollow needle in her neck. Do you know why? Because she's going to cry out, and try to move her atrophied, useless limbs towards me under the drape. Or worse yet, not even move. And I can't explain to her what we're doing. I can't tell her that there are risks to this but we should do it to bring her back to her baseline, because she can't respond at her baseline.

Those of us on the front lines are learning when to say no. No, this poor lady in the twilight doesn't need to be harpooned. She's going away gently already. The central line doesn't beat back time, or raise the veil.