Mr. K. was forty-two and almost dead, kept alive by machines, tubes, and liquids that would at best give him two or three days more. His wife had brought him to the emergency room, probably because he was confused or vomiting or had chest pain. It soon became clear that he had taken too much Vicodin or heroin or any one of a number of potentially lethal drugs, perhaps by accident, perhaps not. No one knew for sure; he’d fallen unconscious soon after his arrival at the ER. We had only his lab results and his family to fill in the blanks, and they told different stories.
He was from Bosnia, someplace I knew nothing about. Under the cold lights of the ICU, his smooth skin shone like light coffee. His wife was from the Philippines. He was Muslim; she, Catholic.
I’d been an ICU nurse once but had scaled — or, depending on one’s viewpoint, descended — the ladder into an administrative nursing position. When I’d swum in the ICU ocean, I’d performed CPR on a regular basis, and I’d cared for many patients who were on life support. I used to tell people what I did for a living was “keep dead people alive.” Machines inflated their lungs and kept their hearts beating so we could officially count them among the living.
I pieced together Mr. K.’s story from conversations overheard in the hallways and comments made by the nurses. For some reason it made me long for the days when I could touch patients with my hands, when I would turn them every two hours or bathe them, imagining each one was my child, my partner, my mother. I still miss the physical intimacy of running my hands across their failing bodies, hoping that perhaps this one will live to see his grandchildren, will walk out of the hospital with a healed body and an able mind.
As Mr. K. got on with the business of dying, his multicultural, multilingual family congregated outside my office, which is just around the corner from the ICU. I keep my office door open, and on the day Mr. K.’s relatives and in-laws arrived, all of them missed the sign for the ICU. I could hear them wandering the halls, murmuring in different languages until they stopped at my open door and waited for me to turn around at my desk. Each group of two or three asked me, in accented English, where Mr. K.’s room was. At first I was as courteous as a new nursing student, but by the tenth or eleventh group of people, I began to tire of my role as information booth. By the time the last batch straggled in, I’d stopped turning around in my office chair and simply interrupted them with a curt “Room 3206.”
There were twenty or thirty of Mr. K.’s relatives in the corridors, small children running up and down, their shoe rubber squeaking on the waxed linoleum. As I determined where to put patients in our overcrowded hospital, the sound of foreign conversations drifted into my office — so many that I closed my door to concentrate. The ICU waiting room, which shared a wall with my office, shook with the sound of cartoons and the shrieks of young boys and girls. In the afternoon I heard arguing and walked over to see a middle-aged man poking his finger into the chest of another middle-aged man while a woman cried in the corner. The first man said, “How do we know you care about us, when you ain’t never visited our house?”
A woman cried, “She’s my baby sister. I can’t stand it.”
A man told her, “You got to. You don’t have no choice. Your babies need you now.”
One woman stood outside my office speaking on her cellphone: “They’re giving him until eight o’clock to die. His liver’s shot. There ain’t nothing there no more where it was. He ain’t got no brain waves neither.”
When death hangs over a patient, the stress for the family becomes almost unbearable. Arguments that have lain dormant for years arise like floating coffins after a flood. Mr. K.’s and Mrs. K.’s relatives, it seemed, had never gotten along. Mr. and Mrs. K. were married; their families were not.
The ICU staff chatted about Mr. K.’s liver failure and approaching death. As medical professionals, we could tell which type of drug had caused his liver to fail, but we could not say how Mr. K. had come to acquire and ingest that agent. According to his laboratory values, Mr. K.’s blood was weighted with foreign substances purchased and consumed in quantities that the manufacturer did not intend. The labs told us that Mr. K. had been medicating his pain, whether physical or emotional, by swallowing or sniffing or shooting drugs into his body, and in so doing had shortened his life.
His family refused to hear this information, insisting that the tests were wrong, that Mr. K. was all that he’d appeared to be: a loving husband and father, a good son. We of the American medical profession knew better. But Mr. K.’s family members were not originally from the U.S. and were suspicious of our pink do-gooder faces. We were liars, telling them that Mr. K. did drugs. We were liars, telling them that he was going to die, when just yesterday he’d been sitting with his three young children, his head thrown back in laughter, his teeth white against his beautiful brown skin. We were wrong. We must do everything we could to save Mr. K.
On Mr. K.’s second day in the hospital, his nurse told me about some changes in his lab values: his blood-clotting factors had been affected by his liver’s degeneration. The fragile mechanism by which bleeding is stemmed has a romantic-sounding medical name: the “coagulation cascade.” A series of blood factors must be present to cause a scab to develop. Too much coagulation causes blood clots in the veins; too little causes us to bleed to death from small cuts. Hemophiliacs are most often lacking factor 8. If any one of the factors is missing, the ones that follow — 9, 10, 11 — will not be able to form. The cascade will become a rushing river, impossible to dam. When the nurses drew Mr. K.’s blood for labs, his bleeding times were quite prolonged. He was running the risk of hemorrhaging.
At his family’s insistence, Mr. K. was what we call a “full code.” This meant that if his heart rate began to falter, rather than allow him to die peacefully — as we did with a “no code” patient — his nurses would perform CPR on him and shock his heart back to life. Because Mr. K.’s blood showed an inability to clot properly, CPR presented a problem. As his nurse put it, “When he codes, he’s just going to start squirting.” Pressing hard on his chest would cause any blood leaking from his organs to shoot up through his esophagus and out his mouth and nose and ears. “It will be a blood bath in there,” she said. “But the wife won’t let him be a no code. When I went home last night, all I could see were his kids’ eyes. He’s got the Catholics praying for him; he’s got the Muslims praying for him. I’m just praying those kids aren’t in the room when he goes.”
I remember the ambivalence an ICU nurse sometimes feels about saving lives. We run and sweat our way through sixteen-hour shifts, doing everything possible to save patients. Yet we know the horror of maintaining life near the end. We are aware of the needless suffering that our patients often endure for the sake of a few extra days or weeks of life, time they will spend as victims of our needles and tubes. Our tasks seem simple enough. For instance, we turn patients from one side to the other every two hours. But this does not tell of the pain we inflict while we lift the sheet beneath frail bones and raw skin. After a few months of hurting people on their road to death, we become cynical. We begin to feel more like torturers than caregivers. We dread those moments when we will be called upon to perform extraordinary measures — CPR, defibrillation — to keep death at bay for a few more hours or minutes. Most often it is against our better judgment that we keep the machines running and the medications flowing, forestalling the death of a body whose soul seems already to have fled the scene. We wish that we, too, could flee.
Mrs. K. had spent the night at her husband’s bedside. On the afternoon of the second day, I saw her drag herself to the bathroom across from my office. She was so tired she tripped on the tile threshold. Mr. K.’s bored children prowled the halls with eyes staring straight ahead, not smiling, not sad. Like the rest of their family, they didn’t understand that their father was dying in Room 3206. The waiting room was littered with potato chips, crackers, juice boxes, Oreo cookies, even cans of Cheez Whiz. I’d expected some lumpia or sticky baklava, but it was all American junk food in that room. There were sheets and pillows on the floor, and in every chair an adult was sleeping.
By the third day, Mr. K.’s family began to accuse us of not giving him the care he needed. They phoned other facilities, seeking a liver transplant. Specialist after specialist explained that Mr. K. was not a candidate for a transplant: he would not survive the trip to the other hospital, let alone the surgery. The family didn’t seem to understand this. There were conferences in which doctors gave him no chance, and the family screwed up their faces and asked again about the odds of survival. The doctors ordered a CAT scan of his head, hoping it would show a brain hemorrhage: perhaps seeing bleeding inside his skull would help the family accept that Mr. K. was dying.
Before the scan, Mr. K.’s mother, his wife, and his sister waited in an empty room next to Room 3206. Passing by, I overheard his mother say, “They don’t understand. Everybody loves him. Everybody.” They wanted us to see how special Mr. K. was. We wanted them to see that, no matter how special he was, he was going to die.
The patient in Room 3207 went for an MRI an hour before Mr. K.’s scheduled CAT scan. Within moments of the other patient’s departure, a voice came over the intercom: “Code blue, MRI. Code blue, MRI.” The operator sounded bored, as if she were announcing a blue-light special on aisle 12. Two nurses ran for the door. Mr. K.’s family began to cry, finally realizing that just moving a critically ill patient could kill him.
The other patient was saved with a quick shock and returned to the ICU. Then it was Mr. K.’s turn. He was wheeled out of the unit with a respiratory therapist for his lungs, two nurses for the rest of his body, and two escorts to push the bed. At least twenty family members trailed behind him, some with arms outstretched. I heard the chanting of prayers, the clatter of rosary beads, and the soft sound of men rubbing the pages of the Koran between their fingers. A nurse rolled her eyes and said to me, “It’s going to be quite a scene when he dies.”
An hour later, the CAT scan complete, Mr. K. was back on the ICU. The family members gathered around the neurologist, who told them the scan hadn’t shown a bleed. The relatives began to clap and cheer. The nurses busied themselves with other tasks and tried to hide their dejection. One told me later, “I hate to say it, but I wish he was brain-dead. Maybe then they’d let him go.”
I didn’t speak to any of Mr. K.’s family when I passed them in the hall; I just smiled and nodded. If they were crying or praying, I averted my gaze, telling myself I was giving them their privacy. I tried to imagine what it was like for Mr. K.’s wife. If it had been my partner in that bed dying of liver failure, would I have understood that there was no hope? I knew I would have longed to shake her awake and ask her how this had happened: how had she gone from laughing and gardening and working one day to living on a ventilator the next? I might have felt lost in the medical terminology, even though I was familiar with it. I might even have found myself reciting ancient prayers that I thought could bring peace to her, or to me.
Later on the third day, a nurse told me that Mr. K.’s wife was “beginning to come around.” Mr. K.’s eyes had no corneal response, meaning when a finger was poked at them, he didn’t blink. His pupils were fixed and dilated, meaning they did not react to light. Both reflexes are controlled by the primal base of the brain. “I think she’s starting to understand that he’s not coming back,” the nurse said.
The rest of his family, though, was still sure there would be a miracle. Two of Mr. K.’s relatives shared an elevator with me as I went down to the cafeteria. The older man said to the younger one, who had sad brown eyes, “They’re trying to kill him. I don’t know why, but they’re trying to make him die.” They both shook their heads.
When Mr. K.’s heart slowed and then stopped for the first time, I could hear the cries of fear from my office, the wailing and yelling that told me of trouble even before the operator’s bored voice announced a code blue. The nurses rushed in with the defibrillator and medications and brought his heart rate from zero back up to a hundred.
Half an hour later, I went into the unit and peeked into Mr. K.’s room. His wife and his mother and his sisters-in-law lay slumped on the bed with him. Two of them had their heads on Mr. K.’s chest, and they flinched with every sigh and beep of the ventilator. Beneath an empty chair sat an open package of Kotex, as if Mrs. K. didn’t have the energy or presence of mind to place it in a more private spot. She was wearing the same jeans and purple T-shirt she’d worn on day one, and her mascara lay in black clumps against her cheeks.
Later I walked by again and saw Mrs. K. crying on her husband’s chest — great, racking sobs with long moments in which she took in no air, and Mr. K.’s family reminded her to breathe. Beneath her, her husband’s lungs deflated and inflated by the working of the vent bellows, and his heart beat in response to a mixture of chemicals.
A few hours later I heard screaming, and again the operator announced a code blue. When I entered the unit, the nursing supervisor and two patient escorts were picking Mrs. K. up from the floor. I bent down and grabbed her heels to help guide her onto a cot, my hand on her bare ankle. Mr. K. had coded and been revived; Mrs. K. had fainted. She’d been three days seemingly without sleep or food. She could not take care of herself while her husband lay dying. She could not grasp that he had led a secret life; could not understand how he’d kept it hidden from her, from their children, from his family. The American doctors and nurses tossed around medical terms like “vasopressors” and “corneal response” and “ammonia level,” as if the words had meaning for her, while her husband was dying of an enigmatic poisoning she had never suspected and would never understand.
That was the last time I saw Mr. K. The next day I had to rotate to another hospital, and when I returned, there was a new patient in Room 3206. A nurse told me that Mr. K. had died early on the morning of the fourth day. “Don’t those people believe in mortuaries?” she said. “They were in the unit all day, moaning and wailing.”
I recalled how, as I’d left the parking lot on the evening of Mr. K.’s third day, I’d seen the young man from the elevator, the one with the sad brown eyes, walking along the shoulder of the road. Perhaps he was Mr. K.’s brother, or a cousin, or a friend. His head was bowed to the setting sun, and his hands were behind his back. I pulled up alongside him and rolled down my passenger-side window, and he stopped and bent over to look in at me.
“I just want you to know,” I said, “that I’m thinking of you and your family. I know this is hard. I’m sorry.”
“Thank you. Bless you,” he said. “Well, you must already be blessed, because you have said this to me.”
We looked at each other, his brown eyes to my brown eyes, his dark skin to my fair. I knew that Mr. K. had overdosed, intentionally or no, and that this man could not grasp that. He thought that we in the medical profession were killing his brother or cousin or friend with our refusal to give him a new liver. Yet, in that moment, as he leaned over to speak to me in my car, I was not a nurse in a white coat, and he was not a foreigner puzzled by our medical world. We were just two humans, connected by the slender line of vision between our eyes.
As I drove away, I kept sight of him in my rearview mirror until I turned the corner and he was gone.
Some details in this essay have been changed to protect privacy.
— Ed.
