"His pressure has been dropping all afternoon," he explains, "and on maximum vasopressors, I don't expect him to live through the night. You might want to come in now".

I am a bit shaken but not surprised, and, having prepared for this news, I race for the door, purging my mind of the day's events in anticipation of what is to come. In the taxi ride uptown I try to imagine what is happening at the hospital and prepare myself for any scenario. Is he dead already or is he still alive? I chide myself for not having predicted more precisely when things would change for the worse and regret not taking the entire day off to be there and provide support.

I arrive, expecting the worst, and run up the stairs to the unit. A small mob of family is huddled around his bed. In extreme circumstances, the two-visitor-at-a-time rule is mercifully overlooked. He's still alive! Fortunately, I am not too late. Glancing up at the monochrome screen, I see the green tracings of the cardiogram, arterial blood pressure, central venous pressure, pulmonary artery pressure, and respirations that testify to the presence of life in the motionless boy. Motionless except for the chest rising at a mechanically precise rate of 20 times per minute.

His heart rate is 160 beats per minute, his systolic pressure is about 55; at least it will not be long now. Looking around at the family, my family, I sense a collective sigh of relief. The doctor is here. The doctor to whom the entire family turns for advice has arrived. Surely he has brought hope to an utterly hopeless situation. Last year it was grandmother's ovarian tumor, the year before it was grandfather's pneumonia. Now the questions that are literally about life and death concern my young first cousin, barely out of kindergarten for "special" children. I never expected to have close relations as some of my first patients, but by now the terrain has become all too familiar and with each passing year and each new relative I learn to negotiate it a bit more smoothly.

As I take a seat and slip into character, the love and warmth of a nephew gives way to a physician's clinical detachment. They want to know everything and I attempt to explain to father, mother, brother, sister, cousin, and uncle the meaning of the gauges and squiggles. They quickly realize which numbers and lines are important, and follow them. We begin to relax, even to smile, but as the second hour gives way to the third and fourth, the family members notice what I realized at the outset. The numbers are going down, the blips that make up the pressure tracings are shrinking. What will happen in the end is clear to everyone, yet mother and father have declined the offer of a do-not-resuscitate order against the hospital physician's advice and my own.

"He's going to die," I explain, breaking the silence.

"We know, but when?" they counter, almost in unison.

"Soon, very soon," I say, trying to sound reassuring.

The conversation turns to happier times in the boy's life, before the leukemia, before the cardiac arrest. They speak of his smile, of his bizarre fascination with pots and pans when he was 2 years old. They recall an episode of his favorite television show.

When he was diagnosed with the Down syndrome shortly after birth, the family grieved. With the support of his parents and siblings and a parade of therapists he reached such a high functional state that he recognized his own predicament and would beg his tutors to "make me smart!" As is common with the disease, he had frequent infections and the family almost lost him to pneumonia very early on. I do not know which played a stronger role in his remarkable recovery, his own indomitable spirit or the unremitting love and patience that his family provided.

Listening to them speak, I think it sounds like a slightly premature eulogy. They cannot let go of him, and when they notice his cyanotic legs they turn to me for an explanation, delaying my own reflections on the imminent death of a loved one so that I can answer their questions.

Just after midnight, my aunt grabs me by the arm and asks that I go with her to speak to the doctor. When I ask why, she says she wants to get an update. An update? Who could be more up to date on the boy's condition than the mother who has spent the last 2 days at his bedside staring at the monitor? Reluctantly, I agree to help her find the on-call pediatric critical care fellow, who has to be awakened from a much needed nap.

"This is my nephew, he's a doctor, so explain to him what's going on".

The introduction embarrasses us both, but the sleepy-eyed man in charge of 12 tiny critically ill patients explains in painful detail the patient's progress. As he reels off numbers corresponding to vital signs and functions, my cousin becomes reduced to creatinine and lactate levels and wedge pressures. I absorb all of the information and make an assessment immediately.

"So?" my aunt asks.

"He's dying. It's only a matter of time now," the fellow replies, echoing my earlier pronouncement.

"But he's a fighter, I know he can pull through".

The fellow looks at me and we share a knowing glance. To be certain, the boy is a fighter. He fought off that pneumonia 3 years ago, maybe he can win this one, too. How does this doctor have the audacity to project so hopeless a prognosis? Whose side is he on, anyway? In my unflagging support for my aunt and family I have lost my sense of reality and objectivity. I catch myself wondering whose side I am on and why I am thinking in terms of "sides" at all. Surely there is no fence between doctor and family, is there?

At three in the morning, his blood pressure drops to below 40 and soon remains in the 30s; his heart rate has dropped to below 130. The hours crawl by as the nurses periodically draw blood gases and give bicarbonate, making sure he does not miss a dose of cimetidine or imipenem. His older sister, who raised him, whispers in his ear and kisses his grotesquely swollen face and hands; I find myself taking more frequent breaks for coffee. Thank goodness he has the chicken pox and we have a private room.

At noon his blood pressure tracing turns flatline, his pulse slows. I join the family in preparing to say goodbye. Mother weeps as father sits in stone-like silence. I call the nurse. She calls the doctor.

He listens to the patient's chest and I feel that my presence is redundant. Even as I hold my aunt I realize that I am a physician also, but without my white coat and stethoscope I must watch from the sidelines, a passive role that is disturbingly similar to the doctor's own. He finishes and shakes his head; there is no pulse and no audible heartbeat, nothing more can be done.

"But he's still alive, look at the monitor," mother exclaims, pointing upward to the screen.

I explain electromechanical dissociation, that the cardiogram tracing will also become flatline soon. We finish crying, kissing, and hugging, and expectantly watch the monitor that reflects a persistent electrical impulse at 95 beats per minute. Two more hours pass, the tear ducts dry, and sleep finally claims me.

I wake up on the floor of the pediatric department conference room and creep back to the unit. He's still alive. Only mother is awake now, holding his pale hand and watching the tracing dance at 1 beat per second.

"He doesn't want to leave us," she says hopefully.

"Yes he does, we just won't let him," I offer, trying to explain to myself my family's behavior.

As a doctor I have explained to the family what is happening to their son as clearly as I know how. Experience with families in the intensive care unit has taught me well. But as family, I am plagued with the uncertainty of what my obligation is and whether it has been fulfilled. I suspect that in the guise of professionalism, I have squelched emotional support to near nonexistence. Does becoming the family doctor make it impossible to serve each role equally? Can the personal and professional be interwoven, or does the part call for a multiple personality syndrome that discerns the invisible signs telling the player which hat to wear? Sometimes it appears that even the simple inquiry "How are you, Dad?" can take on a new meaning and invite responses never offered before I went to medical school.

The monitor starts beeping again, arousing me from self-indulgent rumination. His heart rate is now 60 beats per minute and in a short time the rate drops; the complexes widen and shrink before they disappear, leaving a smooth line. I wait a full minute before calling the nurse. She again brings the doctor, who repeats the ritualistic auscultation.

"I'm sorry. He's gone".

Gone. Dead. Finally, he has died and can rest. The doctor fills out the certificate. The ventilator gently purrs until it is turned off. We watch as the color drains from his face. The paper may certify that he is dead but in our hearts he's still alive.