Why I talk to comatose patients
By James J. McCague, MD
The news of Henry Baker’s admission to intensive care distressed me. Henry, a retired executive whom I’d treated for a neurogenic bladder, had been my patient and friend for many years. His family had known mine for three generations. Henry was a delightful old fellow: Despite Parkinsonism that had diminished his mobility, he retained an active mind and a lively sense of humor.
Now Henry was gravely ill, with cardiac and respiratory failure, possibly caused by a pulmonary embolus. When I visited him in the ICU, I found him unresponsive, incubated, and on pressors. I was heartsick; his family was devastated.
Several days passed, and although Henry’s blood pressure improved and he was weaned from the respirator, he remained unresponsive. Eventually, tethered to his I.V. pole, he was transferred to a private room on a medical floor, where his internists proceeded to monitor his anticipated decline. Although I had nothing constructive to offer, I visited every day.
How do you deal with an unresponsive patient? I’ve always been unsure. Do you ignore him? Challenge him? Reaffirm his level of consciousness at every meeting? I don’t want to reduce the relationship to a one-sided exam-almost a preautopsy evaluation. But I do want to be realistic: I’m haunted by those terrible moments when a patient’s family member tries futility to reach the dying or dead relative.
So I fashioned a compromise. The routine I’ve developed may look a little goofy, but it works for me. I introduce myself when I enter the room. As I examine the patient, I talk about whatever comes into my head-politics, baseball, anything, Then I leave with some upbeat evaluation of the patient’s health, however fanciful. In Henry’s case, I just talked.
Although no one, expected Henry ,to survive the weekend, his family arranged for 24-hour private-duty nurses, who took meticulous care of him. Whenever I paid my late-afternoon visit, the same nurse was pre-sent: a lovely young Filipino woman. The first time she saw me talking to the seemingly lifeless form tucked into crisp white sheets, she stifled a laugh. But after that, she regarded me with quiet bemusement.
As the days stretched into a week, Henry remained unresponsive but clinically stable. Nursing-home placement was discussed, halfheartedly; no one seriously believed it would be necessary. I continued my visits, chattering away about the weather outside, or one of my children. The nurse, I’m sure, doubted my sanity.
By the second week, Henry’s internist had consulted a surgeon about performing a feeding gastrostomy. For several days, I talked to Henry about the nutritional advantage of this approach. In the course of my monologue, I also mentioned that my wife and I were planning to visit Toronto for the weekend to see “The Phantom of the Opera.”
Knowing I’d be absent for a few days, I felt uncomfortable leaving without an explanation. I’d talked to Henry every day since his admission, and although it seems unscientific, I was afraid he’d miss my voice. So I rambled on again about the Toronto trip, telling Henry’s inert form that I looked forward to our visit but was unsure where to stay. I even threw in the names of several hotels the theater staff had suggested.
That’s when Henry opened his eyes. “Jim,” he said, “I suggest you try the King Edward. Vastly underrated. It’s in a nice part of town, close to the theater. A bit old-fashioned, but a lovely lobby, a nice bar, and fine rooms. You and Carol will love it.” I was stunned. And Henry’s nurse looked for a moment as though she might need resuscitation. Then she started rushing about, trying to decide whom to call first. I thanked Henry as casually as I could and left the room.
The King Edward Hotel hadn’t been on my list of suggestions. But with a recommendation like that, how could we go wrong? We booked a room that night. Not surprisingly, our visit there was one of our best weekend vacations ever.
Henry improved, gradually, and left the hospital virtually unchanged by the experience. But I was a bit changed: What I had done as a routine has now become a conviction. I take patients very seriously, regardless of their level of consciousness.
I think Henry’s nurse was changed, too. Every time I see her, she looks as if she wants to touch the hem of my lab coat.