Dean Gianakos, MD
Lynchburg Family Medicine Residency and Geriatrics Fellowship, Virginia, United States
It’s 2 am, and I’m on the phone with my first-year resident, Sherry.
“Dr. Gianakos, I have one of your patients here in the emergency room, Jack Jones. As you know, Mr. Jones is a 72-year-old man with severe chronic obstructive pulmonary disease. He came in tonight complaining of increasing shortness of breath for several days.”
I’m in my robe and woolen socks, sitting in the bathroom with a nightlight on. Through a small window over the bathtub, I can see snow falling on the sill. I scribble down Jack’s name as Sherry reviews the history and physical. She thinks he has had exacerbation of his disorder triggered by acute bronchitis. She says he feels better after a dose of steroids and several albuterol treatments.
She also says he does not want to be resuscitated. I’ve never had that conversation with Jack.
“Are you sure that’s what he wants?” I whisper, trying not to wake my wife.
I’ve known Jack for years. He coached my boys in football through middle school. He worked as a short-order cook at a local diner for 32 years before his disease forced him to quit. I remember the years when he fixed me bacon and eggs on Saturday mornings. Now I see him every three months in the office and twice a year in the hospital. He still smokes a pack of cigarettes a day.
I review the orders with Sherry and tell her I’ll see him in the morning. I climb back in bed and snuggle next to my wife.
Fifteen minutes later I’m awake, thinking—thinking about his code status.
After tossing over a few more times, I kiss my wife’s forehead, climb out of bed, and slip on my clothes. My yellow Labrador wakes up and follows me to the front door. As I drive to the hospital in my snow-covered jeep, I recall the football years with Jack. The snow and moon light the way.
When I walk into Jack’s room, he is sleeping soundly. His respirations are quiet and effortless. His nasal cannula lies forgotten on the pillow, diffusing oxygen into the air. I carefully put it back in his nose without waking him. I walk back to the work cubby where Sherry is dictating her history and physical. Except for the glare from computer screens, the room is dark. I sit down and jot my note. I review her orders on the computer. After a few moments, I look up at Sherry.
“Did Jack mention why he did not want to go on a respirator?”
“He didn’t say, Dr. Gianakos. Then again, I never asked him. I’ve always understood “Do Not Resuscitate” to mean no cardiac resuscitation.”
Speechless, I get up from the swivel chair and motion Sherry to follow me. She’s too young to know many patients can recover on a respirator. In a slight panic, I think to myself, “What if Jack had deteriorated and needed a respirator while I was home in bed? Why have I avoided the code conversation with Jack?”
We walk down the hallway to Jack’s door. I knock loudly and flip on all the light switches my fingers can find. I go to his bedside, where I call his name and vigorously shake his shoulder.
“Dr. Gianakos, I think he’s awake now. He’s definitely awake.”
“Jack. Jack. We gotta talk.”
DEAN GIANAKOS, MD, FACP is an internist who serves as the Associate Director of Lynchburg Family Medicine Residency and Geriatrics Fellowship, Lynchburg, VA. He is an Associate Professor of Clinical Family Medicine at the University of Virginia. He is also board certified in Internal Medicine and Hospice and Palliative Medicine. Dr. Gianakos frequently writes and lectures on end-of-life care and the medical humanities and serves on the editorial board of the medical humanities journal, The Pharos.