Silent Space

Abstract

Exhausted at the end of a busy week on service in the intensive care unit (ICU), the fellow and I are on our way to the conference room to debrief the week. The overhead code alarm disrupts the temporary lull in activity that normally occurs at shift change. We rush toward the commotion coming from the room at the end of the hall. A staccato, high-priority sound fills the air with a jarring electronic noise. Up on the flashing monitor in the room, we see the unmistakable pattern of disorganized electrical activity indicating ventricular fibrillation. The patient's arterial line tracing is flat."Should we shock him?" asks the fellow.The resident and nurses in the room are silently wondering the same thing. As an intensivist, I spent years cultivating in myself and teaching others what should be the instinctual reaction-treat a shockable rhythm with electricity. It is one of the most effective interventions for a patient in cardiac arrest. But this time is different."No," I say, "he's DNR." His heart had a single-digit ejection fraction, and he was admitted to the unit weeks earlier with septic shock. He had suffered enough in his life. He did not want to spend the end of it on a ventilator or in the throes of cardiopulmonary resuscitation. The resident calls his friend and decision maker, who also instinctually wants us intervene but confirms "He didn't want that." She says she will come to the hospital; we all know he will be gone by the time she gets here.We had spoken to him on rounds that morning; he had managed to crack half a smile. His friend visited him at lunchtime. His nurse was in the room just before his heart finally failed for the last time. It all

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