这是绝对没有办法的. 她快死了. I gave her a few hours at best, with maximum pedal to the metal intensive medical care. Paramedics had picked up this homeless woman after she collapsed under a bridge in Oakland, Calif. 她的心脏完全停止了跳动. 她死在那座桥下了. But the paramedics had somehow pulled her back, with a jump-start to her heart. And then brought her right to my service in the intensive care unit.
She had no known family, and the police were trying to track down anybody who could speak for her. 社工告诉我，到目前为止还没有运气.
She was emaciated, with an incongruously large, round belly, hard as a basketball. Her hair was knotted and tufted, her lips cracked and dry around the breathing tube. By the time I saw her, she had already been treated by many health care professionals. They had done CT scans, inserted large catheters into larger veins, and started various drips.
现在轮到我接手了.
形势令人沮丧。. This 51-year-old woman had all of the dreaded and irreversible complications that come with 慢性酒精中毒. 关键器官衰竭. 她的肝脏, the organ that produces the sugars needed for life as well as for clotting and detoxifying the blood, 几乎完全关闭了. 现在是紧绷的疤痕组织, 它的功能就像一个堵塞的筛子, 防止液体回流到心脏. 所以她的腹部有很多液体, giving her the look of a woman in her final days of pregnancy. Her pancreas was in tatters from repeated bouts of 酒精诱发胰腺炎 多年来. Her kidneys had been limping along for months on the verge of failure, 现在已经完全关闭了.
最重要的是, 她深受打击, her blood pressure having sunk to the lowest readings attainable, despite being “maxed out” on blood pressure support medications. 休克可能有几个不同的原因. 我们这些医学侦探, 就像电视节目《老葡京网赌场官网》里的那些,” are driven to narrow down the possibilities until we arrive at an answer. We order numerous tests, many of which are risky and painful. 临终病人, these tests often don’t provide helpful information anyway — they rarely change the outcome, 甚至可能杀死病人.
毫无疑问，这个女人快要死了.
As if this scenario weren’t awful enough, her brain was profoundly and irreversibly damaged. 她头部的CT扫描显示了一幅可怕的画面. 她大脑皮层的细胞, 那些赋予我们人格的东西, 意识, 认知与独立, 肿得快死了, 而且已经没有机会逆转了. 她再也醒不过来了.
但这对I来说没那么简单.C.U. 医生. 我们的训练激励着我们继续前进, 即使很明显我们的病人快死了, and especially if there is no family to consent to putting the brakes on.
所以我的重症监护本能驱使着我. 我可以想象做很多事情. Lowering the acid level in the blood with bicarbonate, 排出她肚子里的液体, 增加降压药, 开始透析. I watched as my residents ran in and out of the room, procuring the various catheter kits that would be threaded into her body to perform these functions.
But I felt another pull too, from another part of my medical 培训 — 姑息治疗. This specialty had taught me an approach to the care of suffering and dying patients that differed from the one I’d learned in my I.C.U. 培训. Over the years I had come to see that the interventions I performed in the name of lifesaving often didn’t help my patients, 反而加重了他们的痛苦, 没有显著的好处.
我告诉我的住院医生我们需要谈谈.
我们在屋外开会. They hovered around me like hummingbirds, barely able to stand still. They were on autopilot, I saw; the impetus to do something was tremendous. I recognized their agitation, and understood how self soothing action — any action — would be.
“Let’s talk about how that’s going to help,” I said, pointing to one of the catheter kits.
老住院医生目瞪口呆地盯着我. 她有工作要做，我在阻止她. 仍有未解之谜. There was a diagnosis to pursue, an acidosis to correct, a big belly to consider deflating.
但这些答案会改变什么吗?我问
他们不断提出新的建议. With each, I asked them how it would change our course. Perhaps I was hoping they could convince me that there was something more we could do to save this woman. Yet the patient was already on maximal treatment, and she was still dying. My resident argued that the right thing to do was to try to keep the patient’s body alive until family came. But our social workers had not found any trace of family after an exhaustive search.
One thing we could do, I pointed out, was to treat her for pain and anxiety. Even though she was completely unresponsive, she may still have been aware of them on some level. These well-meaning 医生s had been taught that the priority was curing the disease, 还没想过要治疗症状.
I too felt most comfortable when I was doing something to address each medical problem. Even if, in the back of my mind, I didn’t expect it to help. Refraining from action went against all of my medical instincts.
所以经常, 当病人濒临死亡时, 我必须保护好自己和我的住院医生, 让我们发痒的手指安静下来, and acknowledge that we find ourselves in the uncomfortable position of waiting for nature to take its course.
For the next several hours, as the patient lay tethered to the machines, we sat on our hands. Because we hadn’t located any family, I didn’t withdraw any existing treatments. But I didn’t let my residents initiate any new ones, either. Not the blood gas, nor the Quinton catheter, nor the arterial line. Instead, I started a careful dose of pain and sedation medications. 我们会坚持到底.
她在几小时内就死了. It was a case I don’t think any of us will forget. 但我相信我们对病人是对的. 我们承认我们救不了她, and resisted the urge to treat her untreatable disease — and instead treated her suffering.
杰西卡·努蒂克·齐特 is a critical care and 姑息治疗 physician at Highland Hospital in Oakland, Calif. She is writing a book about her work, and is featured in “极端情况下,” a documentary by Dan Krauss, which debuts April 17 at the 2016 Tribeca Film Festival.
编辑于2018年6月14日.