THURSDAY: Slow Code

BY ROBERT GREEN

Copyright is held by the author.

VINCE SAT beside his father’s bed. He gripped his father’s hand lightly. Large blue veins protruded between the bruises left from numerous IV insertions on the back of his hand. The room reeked with a mixture of antiseptics and disinfectant. Vince’s big brown eyes were brimming, about to overflow with his hot tears.

“Dad, I feel so helpless. What can I do for you?” he asked looking at the shell of a strong, vibrant man.

There was no response. Vince starred at his dad’s face. He saw his partially open mouth and his closed eye-lids. His raspy methodical breathing was the only sign of life.

The silence was broken when the door opened, and Natasha, the love of his dad’s life, Vince’s mother, entered the room. She wore a forced plastic smile. She came in and stood beside her son and gently stroked the back of his head. Vince quivered, on the verge of breaking into tears.

“He has a strong heart, Vinnie,” she said. “Listen to your father breathing.”

He could barely contain the pain he felt for his mother. He knew better than anyone, that she adored her Giuseppe.

“I just came from St. Francis, Vinnie. Father Pantanolini told me it’s not up to us to ‘play God’ with your father’s life. He could live another ten years. No doctor or you or anybody else can tell when it’s time.”

“Mama, nobody’s trying to ‘play God’ with papa. Try to see the doctors are doing what’s best for him. What’s the point of him lying there, hooked up to those machines? Who’s playing God here? We should be letting him pass peacefully, naturally to a better place.”

Natasha burst into muffled sobs.

“You don’t understand. I love him. I just can’t sit here and let him die.”

Suddenly, Sylvia and her husband Phil, Lilly and husband Peter and their cousins Johnny and Petra entered the room in a whirl-wind. They all crowded around Giuseppe’s bed. Sylvia tried to sooth her mother and quiet her sobbing.

“What’s a matter with you Vinnie? You like upsetting mama for no reason?” she grunted in a low accusatory voice.

“Excuse the interruption,” said a voice from the hallway. The door was opened enough for Dr. Bierbaum to poke his head into his patient’s crowded private room. He raised his eyebrows and motioned Mrs. Catalano to join him in the hallway.

Natasha had great faith in their family’s physician. She was always impressed by his clean manicured finger nails, his spotless white smock, and his grandfatherly face. His bald head with tufts of white hair on each side gave him a scholarly appearance. He looked at her through his half spectacles, perched precariously close to the end of his abundant nose. His kind deep blue eyes surveyed Natasha’s expression.

Vince followed his mother and sat beside her on the neutral coloured institutional chairs in a small alcove off the main hall.

“Oh, doctor,” Natasha pleaded “tell me you are doing everything you can to keep my Giuseppe alive.”

“That’s what I wanted to talk to you about Mrs. Catalano.” Dr. Bierbaum replied.

“Your husband, at this stage of his illness, needs to be kept comfortable. We need to minimize his pain and not do anything to aggravate this process.”

“I know you and the nurses have his best interests at heart,” she said.

“Thank you, thank you for taking such good care of him.”

She shook his hand and said. “Now I want to go back and be with him.”

“Before you go Natasha, I want you and Vincent here to be clear about one thing,” he said.

“It is important you don’t have unrealistic expectations about what is involved in Giuseppe’s care.” Watching her carefully, he continued.

“Sometimes it is wrong to expect resuscitation to succeed without causing further harm to the patient.”

Vince put his arm around his mother’s shoulders to comfort her as she sobbed audibly. He knew in his gut, the doctor wasn’t getting through to his mother.

Vince thought maybe Dr. Bierbaum was too close to the family. Maybe he just couldn’t bring himself to tell Natasha the cold hard truth. He’d always suspected, and now he felt sure, he and the family were not getting the straight goods from the medical team.

After an awkward silence, Natasha looked at her doctor with blood-shot eyes. Her hands were tightly folded in her lap gripping a ball of moist torn tissues.

“I know you’ll do whatever it takes,” she said, “to keep him with us as long as you can.”

Dr. Bierbaum bent over, close to her tear streaked-face. His gentle blue eyes looked at her. He grasped her hands in his. Then he spoke in a comforting hushed tone.

“You know, Natasha, my team and I will do everything we can for your beloved Giuseppe.”

She squeezed his hand and abruptly got up from her chair dabbing her moist eyes.

“You go and be with papa,” Vince told his mother.

“I want a word with the doctor.”

Natasha stroked her son’s face, nodded silently to her doctor, then quickly marched down the hall to her husband’s bedside.

Vince looked directly at Bierbaum. His stunning brown eyes were glistened and were full of tears when he asked,

“You just couldn’t tell her Papa’s not gonna make it, could you?”

The seasoned physician studied him. “I’ve treated your father and your family for many years Vincent,” he began. “I know how your mother feels about resuscitating him. I must either accept her perspective and perform CPR, or ask her to find another physician. I can’t bring myself to do the latter, so I will respect her wishes.”

Vince sighed. It was not what he wanted to hear.

He looked at him and said, “I just wish you could level with her, and tell her we’ve got to let him go.”

The sun had just risen over the mountains. Its rays were just beginning to filter through the tall narrow windows of the 4^th floor nurses’ station.

The early morning stillness was broken by a dull blaring sound.

At the same time a bright red light appeared on a massive board behind the desk illuminating Room 1046 Northwest. The noisy wobbly wheels of a cart broke the silence as it approached from an adjacent hallway.

The phone rang on Natasha’s bedside table.

“Hello,” she murmured.

“Oh, my God,” she gasped.

“I’ll be right there,” she said.

Sylvia was already at her mother’s side. She didn’t need to ask what the call was about.

Natasha was breathless as she spoke.

“We’ve got to get to the hospital right now Sylvia . . . get Vincent, get the car, let’s go. Your father has gone into cardiac arrest again!”

The staff had been briefed about Mr. Catalano in 1046. In the absence of the attending physician and the family, a “slow” code was the implied response.

The team knew patients and their families had the final say — if you are going to die without resuscitation.

The expression on their faces indicated a collective subliminal fear of the dangers the procedure had on the dying. Leaving someone alive, but with severe neurologic damage, was not a successful outcome.

Entering room 1046, they knew the decision was out of their hands. The monitor above the bed was not blinking. A single narrow green line stood out against the screen’s blackness. One of the team switched off the power. For a moment, they stared at the man in bed, captivated by his serene countenance.

Dr. Bierbaum comforted the Catalano family as soon as they arrived.

He spoke to them as a group, in the deserted hospital reception area.

“Your father, your husband Natasha, passed painlessly this morning.”

He continued. “The team attending him said they marvelled at the tranquil expression on his face.”

Natasha was inconsolable, and unable to speak. She only nodded her head, her cheeks soaked with tears.

“I want to see my Giuseppe,” she wailed in her high pitched voice. It echoed down the still deserted halls of the fourth floor.

“Come, mama, we’ll go together,” said Sylvia supporting her mother. Taking her arm she could feel her mother’s body was limp with grief. She was barely able to stand or walk unassisted.

Vince, guided the doctor aside, and whispered.

“Looks like Dad took charge of his passing after all,” he said.

The doctor nodded. “You may be right Vince.”

He shook Dr. Bierbaum’s hand. He realized for the first time, the tight rope this physician walked for the benefit of all concerned.

“Thanks for all you did for him, Doc. And thank you for the compassion you showed dealing with my mother during this difficult time.”

Dr. Bierbaum nodded without speaking. He suppressed the momentary urge to let his emotions show through his clinical facade.

Later that day, after he’d finished his rounds, the Catalano’s family physician sat at his desk and looked out the eighth floor window of his office seeing but not seeing the beautiful mountainous landscape.

I would rather have had the conversation about resuscitation take place openly with the Catalano family, he thought.

I abdicated my responsibility. I tried to satisfy the unrealistic demands of a family unwilling to let their loved one go in peace. I gave in, he concluded.

I should never have let my feelings override my own clinical know-how, he mused to himself.

I passed the buck, leaving the decision to use a “slow code” up to the cardiac team.

Slow Code, he thought. There was no such terminology. It didn’t exist in hospital policy manuals or on patient’s charts. Medical professionals whispered it to themselves in quiet hospital corners. Had this unspoken form of care for the dying become the norm?    

Are we going down the road to half-hearted care for the hopeless? He wondered.

A thought flashed through his mind as he stared into space. Almost at once, it gave him a feeling of solace and peace. It dawned on him that Giuseppe’s passing wasn’t decided by a medical code. It wasn’t determined by Natasha, Vince, a physician or the cardiac team. A peaceful calm washed over his psyche.

“As a scientist and healer, maybe I need to consider these unanswered questions aren’t in my domain,” he said aloud.

Who, then, ultimately determined whether Giuseppe Catalano should have been resuscitated this morning?