In helping all of these new interns get acclimated to life in the hospital, I starting reminiscing with my classmates our experiences as interns. The time when the power went out, and we had to go to the bathroom with flashlights (the hospital has a generator, but only to keep the ventilated patients alive, not to light our bathroom). The time when J got a call at 3am because the night nurse "was just wondering" why we were collecting a 24 hour urine sample on the patient. The time when we had 7 of our patients die in 7 days on the Hematology-Oncology service. The time I broke down sobbing after a night in the MICU...

I'll never forget that patient. She was in her upper 50s and had been diagnosed with metastatic breast cancer a few months back. She was admitted to the medical ICU (MICU) straight from the ER for respiratory distress. We tried to do everything we could to not intubate her. She had metastatic disease to the lungs and brain. Her prognosis was poor. In my opinion, this was it. After a discussion with her, she elected to be intubated (I don't blame her; struggling to breathe is not fun and if you offer someone a way to not feel like they are suffocating, 9 times out of 9, they'll take it).

She had a younger sister, who visited every night after work. And I mean late, like 11p - 2a. Both of the women sang in the church choir, and you could tell they had a special bond. I would update her on her sister's condition, answer some questions, and undoubtedly end up listening to some stories about the patient. We are q3 in the MICU, so I spent a few nights up listening to the sister sing, laugh about their childhood memories, etc. I surely would have loved to go to bed, but I felt like this woman needed someone to hear her.

It became obvious that the patient wasn't going to make it. She got a pneumonia and her blood pressure was dropping. We had to augment it with medications or it would go so low she would lose perfusion to her brain and other vital organs. I began having conversation with the sister about Code Status - would the patient want us to do chest compressions, etc if her heart were to stop beating. I explained that with the infection and the overall state of her sister's health, she would NOT survive the code. It would be futile. Plus, with metastatic cancer, what exactly would we be bringing her back to? After days and days of discussion, I was finally making headway. Why, I asked, put her through the pain of broken ribs and electric shocks...shouldn't we just let her go home to God?

Her sister was torn, but did start to see the logic in what I was saying. She told me that their pastor was coming the next day, and we could all discuss it then. I was on call that night, and we stayed up again, and the sister even got some of the maintenance men to join her in a few church songs!

The next day, I was eagerly awaiting the pastor. Finally, I thought, someone who will convince the sister to let God's will be done. I met the pastor, and updatee him on the patient's condition. I talked to him about Code Status, the patient's prognosis and how she would not survive the code regardless. He looked at the 2 of us, looked at the patient, and said after a thoughtful pause, "We must do everything possible." My heart sank, and with it any hope of saving this woman from the pain and futility of the code. I don't even remember if I said anything, I was so in shock. I think I just nodded and walked away. Stunned.

Just a few hours later, the patient's blood pressure took another dive. Unresponsive to medications and fluids. I was just about to walk out the door to go home, after my 30 hours on call. I saw what was happening, and I told the nurse to call the code.

I put my backpack down and went into the room. I ran the code with the Attending. After 15 minutes of chest compressions, broken ribs, IV placement and rounds of medications, I called it. Time of death: 1:35p. I went out to tell the sister, who began to sob. I simply looked at the pastor with disbelief, and I couldn't help but think: this is your fault -- she could have been with her sister as she drifted off, but now she has to hear the news second hand and wait in the hall while everyone files past her, going back to what they were doing before they were summoned to the MICU by the code pager.

I got home and went to bed immediately. My husband came home and woke me up. In my delirium of near-wakefulness, I told him the story and began sobbing. I cried because a young patient lost her life. I cried because a loving sister lost her best friend. And I cried because a pastor -- who is supposed to understand that there is far more to this life than the present -- wouldn't step up to the plate and make a decision to let her go. I hated him. I hated that pastor for what he did and how he mislead that sister. I understand now that people who don't deal with death have a hard time embracing it, though I do hope that he learned as much from that patient as I did.