Dean Gianakos, MD
Lynchburg Family Medicine Residency, Virginia, United States

It’s after midnight, and I’m on the phone with the family medicine resident.    

“Dr. Gianakos?  Sorry to wake you. I’m here in the emergency room with Hattie T.  I know you know her from previous admissions.  Another COPD exacerbation, Dr.G. I’ve given her antibiotics, steroids, and three neb treatments.  She seems to be turning around.  Vitals are stable, and she’s moving more air right now. Last blood gas looks okay- pH has increased to 7.32. I think we can manage her on the pulmonary floor tonight.”

There is no need for me to probe for more details. Mike is one of our best residents.

“Sounds good, Mike. What about her code status?”  

“Say that again, Dr. G?”

“Sorry, I’m trying not to wake my wife. What’s her code status?” I repeat.   

“Right.  Well, she cut me off pretty quickly.  She said something like, ‘You doctors depress me!  I’m not ready to die- and don’t ask me again!”

“Okay, fine.  Don’t take it personally, Mike.  That’s Hattie being Hattie.  I’ll talk to her in the morning.  Call me if anything changes.”

In the past, Hattie has told me she wants to stay alive as long as possible.  However, I feel compelled to verify her wishes every time she comes in. Patients sometimes change their minds.  They don’t always understand what they are asking for when they ask for everything to be done. 

In the morning, Hattie is first on my rounding list. Standing at her door, I holler out, “Knock, knock, Hattie, it’s Dr. G.”

“Come on in,” she says.

I enter and walk toward the wall opposite her bed.

“Do you mind if I turn off the fan and television?”          

“Fine, go ahead.”

“How are you doing this morning, Hattie?”

“I’m better- they removed the BIPAP machine a few hours ago.”  

In the past year, Hattie’s been in the hospital every month for COPD exacerbations.  Some are triggered by pneumonias, colds, or allergies- others by family fatigue or personal stress. She required mechanical ventilation during two admissions. 

She still smokes several cigarettes a day.  At home, dressing herself causes dyspnea. She uses a motorized wheelchair to get around. Her two daughters provide 24 hour care. Like many COPD patients, she also has significant anxiety. 

“You’d be anxious too if you couldn’t breathe”, she tells her doctors. “Try breathing through a straw sometime.”    

“Hattie, do you mind if I sit down?”

“Help yourself.”

Sitting upright in a tan recliner, Hattie looks older than her 75 years.  Her face is black, full, and wrinkled.  She uses pursed lip breathing.  Steroid bruises cover her thin arms.  There are also dark bruises on her abdomen from insulin injections.          

I sit down on a stool in front of her swollen feet, careful not to tangle my feet in the oxygen tubing.  My protective gown drapes over the floor. I ask Hattie a few more questions, and then I get up to examine her.  She has wheezes throughout her lungs.   

After my examination, I roll the stool closer to her. I put the stethoscope on the IV pole, and place my gloved hand on her shoulder.  I briefly glance at the erasable board on the wall.  Below Hattie’s name, I can see that goals of care have not been written yet.      

“Can we talk, Hattie?”

She knows me well enough to know what’s coming next.

She quickly pulls away, and says, “You mean, can we talk about death?  Why do you doctors keep asking me about that?  My lungs are bad. That’s no mystery. I know I’m going to die- only God knows when.  I’ll tell you the same thing I tell every doctor who asks; the same thing I told the young doctor last night, and the same thing I told you a few months ago. I want everything done to keep me alive.  What don’t you understand?”    

Hattie has probably had the code talk over 20 times in two years- residents, attendings, emergency room doctors, and specialists, all doing their jobs to elicit patient preferences regarding code status.  She has heard many variations on the talk. The short versions- ‘do you want CPR, Hattie?’ And the longer, more nuanced versions.  I don’t blame her for feeling irritated.  

“Hattie, I hear what you are saying, but last time you were in the hospital, you mentioned you might consider hospice care.  What are your thoughts about that today?” “Hospice? I don’t remember saying anything about hospice!  I beat death twice this year - what makes you think I can’t beat it again?  I don’t remember being on a ventilator, so don’t talk to me about suffering on a machine.”

I pause, and then let out a quiet sigh.  Yes, she beat death months ago. I refrain from mentioning that her disease and function have significantly worsened since then.  “Maybe you can beat it again, Hattie, and I really hope you can- I just want to make sure you understand- “ 

“Understand that you are getting tired of fighting the battle with me?”

“No, no, Hattie. That’s not it. It’s just that some of my patients in your situation would make a different choice.  Some of them would say to me enough is enough- don’t put me on any machines again, or press on my heart if it stops. Others feel like you do."

I sense her appreciation I’ve taken the time to make sure she is clear about what she wants- even if it gets a little ugly.  Through the bluster, I recognize her vulnerability.

“Okay, Hattie. No more code talk today.  I will certainly respect your decision-“ 

“Even if you don’t agree with it!” she interrupts. 

Hattie has had the last word this morning. We both smile at one another.  I put my arms around her, and she puts her arms around me: communication we both understand. 


Dean Gianakos, MD, FACP is a general internist who serves as the Associate Director of Lynchburg Family Medicine Residency, Lynchburg, VA.  He is board certified in Internal Medicine, and Hospice and Palliative Medicine. Dr.  Gianakos frequently writes and lectures on geriatrics, end-of-life care, and the medical humanities.  He serves on the editorial board of the medical humanities journal, The Pharos.