Communications to the Editor |

A Concussive Clinical Coincidence FREE TO VIEW

Constantine A. Manthous
Author and Funding Information

Bridgeport Hospital and Yale University School of Medicine Bridgeport, CT

Correspondence to: Constance A. Manthous, MD, FCCP, Bridgeport Hospital, 267 Grant St, Bridgeport, CT 06610; e-mail: pcmant@bpthosp.org

Chest. 2004;125(4):1593-1594. doi:10.1378/chest.125.4.1593
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Published online

To the Editor:

I arrived on Monday to begin a 2-week stint as attending in our medical ICUs. The first patient was an elderly lady, who had been in hospital for a month with newly diagnosed HIV and Pneumocystis carinii pneumonia. She unexpectedly experienced grand mal seizures and was intubated for airway protection. Brain imaging and lumbar puncture were unrevealing. Her status epilepticus was complicated by aspiration pneumonia-related septic shock, with prolonged hypotension requiring pressors for > 48 h. Acute tubular necrosis developed, which was beginning to resolve by my advent to the service. The patient had been in a deep coma for 3 days since cessation of her seizures. She did not move to deep pain, her pupils were minimally reactive, and she triggered the ventilator occasionally. The house officers presented her as a case of anoxic encephalopathy—the diagnosis suggested by the consulting neurologist. “When did she code?” I queried. “She didn’t” was the response. She remained in her slumber, essentially unchanged, except that she began to move her left arm, nonpurposefully, to deep pain. An EEG demonstrated a paucity of activity—no seizures, but brain waves that portended a very poor prognosis. The consulting neurologist pronounced that there was little or no hope of meaningful survival. Although I felt uncomfortable, not understanding the mechanism of her coma and still suspicious that it was related to multiorgan failure and polypharmacy, the brain waves seemed like incontrovertible evidence that her chances were very poor. I arranged for a family meeting to discuss ongoing management. I have been, historically, the typical “flea”—the last one to give up on patients. And for days, the housestaff and nurses were adamant that we were doing our patient no favors by keeping her alive, languishing on the ventilator.

The patient’s daughter and her husband, both in their mid-30s, arrived for the meeting. They were polite and thoughtful, but clearly distressed by what was happening. I explained that our patient remained in a deep coma, with little change, likely as a result of multiple combined insults (seizures, shock, medications, HIV itself). In such cases, I often suggest that there is little likelihood that the patient will leave the hospital or return to his/her former self, but usually leave “room for a miracle.” Although it may hold out false hope to some, this approach generally avoids the pretense of omniscience that many patients and families find unsavory. I further explained that one likely scenario was for her to recover to the point of a vegetative state, with possible feeding and tracheostomy tubes, and risks of complications associated with prolonged hospitalization. “Mom would not want to be taken off the ventilator—we think that God will work His miracle.” If she died spontaneously, however, they would let her go without cardiopulmonary resuscitation.

I left the meeting satisfied that we had helped the family in the process of beginning to accept the loss of a loved one. A nurse approached me in front of the coffee machine. “Did you know that (the patient’s) son-in-law, sitting to the right of you in the family meeting, was a patient in this ICU 2 years ago and that you told his wife, sitting to the left of you, that he was unlikely to leave the hospital?” I see hundreds of patients and their families each year. I am really bad with names and faces, beside the fact that I rarely get to see successes—walking, talking, fully functional people who have survived critical illness. “No,” I replied, “but now my opinion probably doesn’t impress them too much!”

The day following our family conference, the patient began to rally. Each day brought a new tiny step in neurologic improvement. One week later, she was opening her eyes. Her repeat EEG showed remarkable improvement. She was extubated and went on to a long recovery (still in the hospital 2 months later). She did not return to the vibrant lady she had been, but she recognized her family and was able to spend quality time with them.

I saw her daughter and son-in-law in the hallway recently—I had gone off service just as she improved significantly and did not have a chance to speak with them about it since the initial family meeting. To my surprise, they seemed very grateful. I acknowledged that I had been wrong in both cases—and that her mother’s case was remarkable. I admitted to learning an important lesson as a result of caring for her. Seeing them sparked a curiosity—could I have been so wrong, so coincidentally? I visited medical records to see what I had documented in the case of the son-in-law. I often write a note when I think care of a patient is approaching futility and document such conversations with families. The son-in-law had had severe multisystem organ failure and sepsis. Although I sensed urgency in my notes, I never documented that I thought care was hopeless. However, I often prepare families for the worst if patients are doing poorly, and likely started that process in his case. The wife had taken away from our discussions that I did not think her husband would survive. In her eyes, I was now 0/2. I was happy that I was wrong, but worried by this degree of imprecision of my prognostication skills. As the Chief of our ICUs, I am expected to be the most knowledgeable, the least likely to so grossly goof.

I read recently in the New York Times Magazine that a neurologist was working with patients in prolonged vegetative states—that he would perform a manipulation and they would suddenly awaken and become communicative. After stopping his “maneuver,” patients would fall back into the abyss. On first consideration, it sounded like hooey to me. Or maybe not.

A fellow countryman once suggested that “a wise man is one who does not pretend to know what he does not know.” Irritated Athenians made him drink hemlock “for corrupting the young.” I often ponder how many patients whose loved ones are told “there is no chance” would have survived to full recovery with best care. This conversation happens countless times each day, in countless hospitals, but infrequently provides the consolation of certainty. My wife, a surgeon, says that to do this job we must do it confidently, with compassion, and to the best of our ability. No one can ask for more. But to stand in the rent between here and there, humility comes in mighty handy. Too much is as-yet undiscovered or unknowable.




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