Exhausted at the end of a busy week on service in the intensive care unit, the fellow and I are on our way to the conference room to sit down and debrief the week. The overhead code bell 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 alarm 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. Our 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 our unit weeks earlier with septic shock. He had suffered enough in his life, and 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.
In this moment, I feel and see on the faces of those in the room how excruciating it can be not to act. Particularly in the ICU, where errors of omission are often deadly in a matter of minutes and so many issues appear to have a solution in the moment.
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 gave out for the last time. It all seemed so sudden. And yet in a sense it was expected, the end the of a long arc of a difficult life with progressive and incurable organ failure. I had noted earlier in the day how we were supporting him knowing that “eventually something bad will happen.” It was unexpectedly prescient.
In the corner of the room, the red code cart sits idle, its drawers unopened. The well-trained ICU nurses had wheeled it in moments after he arrested. But now the standard accompaniments to a resuscitation are conspicuously absent—no beeping of the defibrillator, no hissing white noise of oxygen flowing, no hastily-opened packaging or spent syringes from resuscitation medications at the end of the bed. Instead we all stand quietly, avoiding eye contact, our gazes shifting intermittently between him and the monitor as the electrocardiographic tracing flattens into asystole. We reach up intermittently to pause the alarms that pierce the silence.
After several minutes, the fellow runs through the checklist without speaking.
Absence of respirations.
No pulse.
Pupils fixed and dilated.
Time of death declared.
His nurse turns off the inotrope and vasopressor running through the catheter that had been his lifeline.
We begin to shuffle out into the hallway. “If we could all just pause for a moment of silence,” I ask.
We all stop, turn toward him, and stand together in the now-quiet ICU room. We note both the absence of sound and our own presence in the moment. Emotions swirl inside us—shock at the suddenness of the events, uncertainty whether anything could have prevented it, and perhaps some relief that he did not suffer needlessly in death—as we each silently mark the end of his life. Later the resident will tell me how important this time was. I still remember when I was an intern and a senior resident first modeled a moment of silence after a patient died.
“Thank you all.” My voice breaks the air.
We begin the peculiar rituals that follow death in the hospital, leaving his room to complete the death certificate and other necessary documentation. His nurse remains behind to complete her documentation and prepare his body for transport to the morgue. I send a text message to my wife, who I know is currently wrangling our two young boys into bed. “I’ll be late. My patient just died.”
The fellow and I finally make it back to the conference room. We know this will be a different debriefing than we had planned. We sit, silently, until the tears flow.
We face an inherent tension in caring for critically ill patients—the value of compassion in helping patients and families navigate critical illness paired with the pain that comes when so many of our patients ultimately die. How do we navigate this emotionally treacherous ICU environment today, tomorrow, and the day after, over decades of clinical practice? Certainly, organizational strategies and systematic solutions are essential in the ongoing effort to mitigate the epidemic of burnout in medicine. But we cannot organize away the trauma of witnessing a fellow human being die. Or of feeling irrationally culpable even when we do all we can for our patients. Consequently, we must create space in the chaos and cacophony of the ICU to consider and embrace the profoundly human experience of our work.
In my office hangs a print of the “The Doctor,” an 1891 painting by Luke Fildes depicting a physician at the bedside of a dying child. Silence seems to physically hang in the air, surrounding the physician and his patient. He is not intervening heroically to save the child’s life, but simply bearing witness to the excruciating inevitability of her death. It is easy to forget today, when we have at our hands life support available for seemingly every organ system, that so much of the value we bring as human beings in the health professions remains in our role as witness to the experiences of illness and death.
Sometimes we need not say or do anything other than to be present, and momentarily silent, for our patients, their families, and ourselves.
Ian Barbash, MD 
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