Baylor University Medical Center Proceedings October 2017 - 471

Viaticum
Robert Fine, MD, and Jeffrey Michel, MD

Jesus on the night when he was betrayed took bread, and
when he had given thanks, he broke it and said, "This is my
body which is for you. Do this in remembrance of me." -1
Corinthians 11:23-24

We never spoke and were never formally introduced. I didn't
even know her name. But when the CPR ended, I held her
hand as she died.
The cardiovascular intensive care unit fellow had texted
me 45 minutes earlier, making sure to leave out any personal
identiﬁers including her name. We had to be careful not to
violate the Health Insurance Portability and Accountability
Act of 1996 (HIPAA). Violations of HIPAA could mean ﬁnes
of tens of thousands of dollars. Worst case, a doctor could do
time in federal prison.
I knew she was more than 80 years old and had come in
with an ST-elevation myocardial infarction (STEMI). I learned
that she lived in hospice and carried a diagnosis of dementia.
"Medicine svc?" I texted the fellow.
"Medicine won't take STEMI" was the reply. "ER called
STEMI."
Calling the interventional team in the middle of the night for
this? What about her dementia? What about the hospice? What
were we doing? Experience told me to get dressed and head to the
hospital. I arrived in the emergency room in less than 10 minutes
and met the nurse who had accompanied the patient from hospice.
"She is not DNR," she told me. "The family had discussed
it in the past but couldn't reach an agreement."
"She is in hospice?"
"Yes."
"But she is not DNR."
"Yes."
I quickly moved to the nurses' station and grabbed a phone.
I dialed the family contact listed in her electronic health record,
a daughter who lived in a town nearby.
"This is Dr. Michel calling from the hospital."
"Yes? How is Mom doing?"
"Well, she is having a big heart attack, and I wanted to talk
to you about that. I wanted to make sure that we are doing the
right thing as we work to take care of her."
"Thank you. Well, of course. Please do whatever you think
you need to do."
Proc (Bayl Univ Med Cent) 2017;30(4):471-472

"Okay, well, that would mean taking her down to the lab
and putting tubes into her arteries and trying to open the blockage causing her heart attack."
"Okay."
"But I wanted to make sure that she and you, . . . that the
family would want that."
"Of course! We want you to do whatever you need to do
to save her if you can."
"But she has dementia? And is in hospice?"
"Yes. I saw her today. She seemed ﬁne. She didn't mention
feeling at all sick. Of course, she doesn't talk much. But she
seemed happy."
"And she would want to be treated aggressively?"
"Is there a less aggressive treatment that would work?"
"Well, no."
"Okay then."
"Okay."
The mechanical drives clanged as heavy doors opened, revealing the large trauma bay. Small, thin, pale, and gray, my
patient lay motionless in a heap on a gurney, the center of
attention. A heavy-set nurse towered over her, arms extended,
applying 100 compressions a minute to her chest in guidelineperfect order. I thought I heard an occasional crunch. Ribs
breaking? A respiratory technician stood near her head using a
black bag to force air into her lungs.
I felt some relief. Perhaps this would end here and now.
"I have a rhythm," an excited ER resident exclaimed. "Stop
CPR."
"Let's get her to the lab!"
I had to move quickly to avoid being run over as patient
and gurney, propelled by a stampede of physicians, nurses, and
technicians, erupted from the room.
Time is myocardium. Door-to-balloon time is a quality
metric. Our exceptionally fast door-to-balloon time makes us
From the Office of Clinical Ethics and Palliative Care, Baylor Scott & White Health
(Fine), and the Division of Cardiology, Scott & White Memorial Hospital, Temple,
Texas (Michel).
Corresponding author: Jeffrey Michel, MD, FACC, Interim Director, Division of
Cardiology, Scott and White Memorial Hospital, Assistant Dean for International
Education, Texas A&M Health Science Center, 2401 S. 31st Street, Temple, TX
76508 (e-mail: Jeffrey.Michel@BSWHealth.org).
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Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings October 2017