That Good Night

by Sunita Puri

  4. Offer empathy. “I wish” statements can be helpful.

  “I wish there was something like a laser therapy that we could do,” I said. The interpreter spoke. And a heavy silence followed.

  5. Allow for silence and expression of emotion.

  When I couldn’t stand the silence any longer, I went off-script. “What are your thoughts on this, Mr. Tan? What do you think you want to do?” As soon as the words stumbled from my mouth, I wanted to push them back in and swallow them.

  About what? he wrote, expressionless.

  About the fact that you’re suffering from the complications of the treatment for your cancer, and every time we think we have treated one complication, another one shows up. About the fact that you have been in the hospital for three weeks and you probably will be in and out of the hospital until you die, probably here. About the fact that you could have a huge stroke anytime and we can’t prevent it or fix it. About the fact that I’m afraid that your heart might stop if you get really sick, and I’ll break your ribs and hurt you if I have to do CPR.

  My words raced in my mind but stuck in my mouth. It was clear from the palpable tension in the room that neither Mr. Tan’s family nor I had ever had this type of conversation. And yet now that this subject had been broached, no matter how awkwardly, we needed to grapple with his mortality, which was now as obvious and tangible as the stench of his mouth burned by radiation, his recently used urinal hooked to the side of his bed. I couldn’t help but wonder whether, instead of providing honesty and guidance, I had caused only fear, alarm, and confusion. “I guess . . . I mean, do you want us to do everything we can for you if that big stroke happens? Even if it ultimately wouldn’t help?” I wanted him to tell me that he wanted to die peacefully. I didn’t know how to tell him that we were already doing everything we possibly could to prevent another stroke. And I couldn’t bring myself to admit that there was little more we could do if he suffered a stroke. I couldn’t find the words.

  Mr. Tan looked at his notepad and wrote again.

  Don’t read this aloud. How long before I kick the bucket?

  I pursed my lips tightly. I was a fledgling intern, a neophyte doctor. How could I possibly tell him how long he had to live? And yet, how could I have attempted this conversation without anticipating that he’d ask me just that? Wouldn’t I want to know if I were him?

  I studied him. His temporal artery pulsed visibly at the corner of his forehead. Bruises from IVs darkened his arms. At any time, any one of his complications could suddenly take his life: a huge stroke, another sudden bleed from his belly, a terrible infection with an antibiotic-resistant bug. But what if none of that happened? If he did manage to leave the hospital?

  “Probably months,” I wrote on his notepad. I worried that Noelle and Laura would ask what we were writing, that they would demand that I read our conversation aloud. “I can’t say exactly how many, but that is my best guess.” I paused and wrote more. “I am also worried that you might have a very bad stroke that would keep you from ever leaving the hospital.” He looked at me and erased my words.

  Sorry doc but you are wrong. I plan to walk out of here with a cup of coffee in my hand. He paused, and wrote more.

  And I will see my daughter graduate from UC Davis in two years.

  As if to demonstrate that he meant business, Mr. Tan put down his notebook and pushed himself up in bed. He carefully placed his right side on his pillow and rose to a fully upright position. Small beads of sweat dotted his forehead. His nurse rushed in. “No, Mr. Tan, you can’t stand up alone!” she said, seeing that there might be no stopping him.

  But Mr. Tan didn’t listen. He grabbed the handrail of the narrow hospital bed with his good hand and steadied himself. He stood up right in front of me, wobbling at first, then growing sturdier, then still.

  His nurse stood next to me and I sensed her fear and uncertainty. Somehow, I understood Mr. Tan’s rising from the bed to be just a gesture of emphasis rather than defiance, his way of underlining and boldfacing what he had written with his shaky hand. He stood inches away from the nurse and me, his gray hospital gown hanging off his ghostly frame. He looked around the room for what seemed like minutes, quietly determined, saying nothing, before slumping down onto his bed.

  “I understand,” I said, in awe of what I had just witnessed, unsure what else I could possibly say. As he lowered his body onto the bed, I wondered how I could get out of his room as quickly as possible. “I know we’ve talked about a lot of really hard things today and I hope I didn’t upset you or cause any confusion.” The interpreter spoke to Laura, and turned to me with a question. “She wants to know if it is okay not to talk about this again.”

  Her words stung, but I forced myself to smile and respond, “Of course. I know this was a little awkward. I didn’t mean to upset you. I just wanted to, you know, try to make sure you all know everything that is going on with his health.” Laura, Noelle, and I shook hands, and I promised Mr. Tan I’d be back in the morning to check on him.

  Thank you for your time, he wrote on the whiteboard, followed by a thumbs-up sign.

  I retreated to my call room—the room reserved for the on-call resident to sleep in while at the hospital overnight—for some quiet. I replayed the meeting in my head, squirming at my questions and the family’s confusion and bewilderment. My intention to provide clarity and guidance had only led the Tans to request no further such meetings. What would I do for him now if the worst happened? The default protocol would be to offer every extreme life-sustaining intervention possible. I imagined him undergoing CPR, or attached to a ventilator, and felt nauseated. If his heart or breathing stopped, our machinery might restore his heartbeat, but almost certainly wouldn’t bridge his body, already ravaged by fungal infections and pneumonias and bleeding, back to the health he’d probably expect. Our technologies might prevent him from dying, but they would almost certainly fail to restore his quality of life. More intervention would almost certainly mean doing more harm. And I had taken an oath to do no harm.

  Overwhelmed by the ramifications of my well-meaning but poorly delivered words, I found myself wanting to call my mother, to find out how she had grappled with her own mistakes, how she had managed to find peace when she retreated to her own on-call room, the place she went to to pause and make sense of what she encountered every day.

  * * *

  I was seven years old and in second grade. My brother, Siddarth, was four years old and in preschool. It was a three-day weekend, sometime in January or February, and, as usual on long weekends, my mother had woken us up at six a.m. and taken us with her to work. Neither she nor my father could take a day off from their jobs to watch us at home, let alone take us on vacation to Catalina or Palm Springs or Morro Bay, the places my classmates went with their families, all places we would never visit.

  We stuck to a routine those mornings. First, we would stop at the cafeteria and get snacks. I always chose a Grandma’s fudge brownie with nuts, eager to rip off the red and brown plastic packaging and quickly devour it. My brother, who even at the age of four was the healthier eater, favored Cheerios and milk. The hospital had recently installed a frozen yogurt and ice cream machine, but my mother firmly marched us both past it. She noticed what my brother and I liked from the cafeteria, and she often brought home Grandma’s brownies, boxes of cereal, and leftovers from anesthesiology lunchtime potlucks that she and her colleagues organized.

  After the cafeteria, we followed our mother down the fluorescent-lit hallways of the hospital, past nurses’ stations with stacks of stamped papers, past sets of elevators ferrying patients in wheeled beds and long poles with hanging bags of fluid, past the surgeons’ lounge, where there was always a box of pastries surrounded by abandoned Styrofoam cups.

  “Rita, you’re here with your munchkins!” a tall nurse called out from behind us. I never remembered her name, but I can never forget how she envelop
ed my brother and me in loving hugs, leaving on us both the scent of flowers. “Be good today, kids,” she said, “and I’ll give you more stickers!” The stickers she gave us never made sense to me. Small, round, and multicolored, they had one word on them: STAT. I had seen her place yellow stickers on one set of papers, red on another, and green on yet another. Nonetheless, a sticker was a sticker, and she gave my brother and me plentiful multicolored STATs, which we then used to decorate everything from the birthday cards we made for our parents to our cat’s flea collar. My mother smiled her usual large, glowing smile, waved to her colleague, and continued to walk quickly down the shiny, squeaky hospital floors toward her call room.

  My brother ran into the room and turned on the TV immediately, then arranged his small body on the bed. As he ate his Cheerios, I watched my mother remove a small figurine of Lord Ganesha, the elephantine Hindu deity revered as the remover of obstacles, from her purse and place it on the desk next to the bed. Setting an apple from the cafeteria next to the tiny statue, she closed her eyes and clasped her hands together in prayer, just as she did every morning after rising and every evening before sleeping. I heard her whispering the Gayatri mantra, a powerful prayer for God’s protection and guidance, the first prayer she taught me as a three-year-old child. I would learn years later that, in her practice of medicine, science and spirituality sat side by side; she prayed every morning for God to help her do the right things for her patients, to help difficult procedures go smoothly. As an anesthesiologist, there were ways she came quite close to playing God. She administered medications to put patients into a deep sleep, manipulate their breathing, heart rate, and blood pressure throughout a surgery, and awaken them afterward, asking them to breathe, to tell her where they had pain so she could treat that as well. My father would tell me years later that my mother would take on medically complex, fragile patients whom other anesthesiologists didn’t feel comfortable taking to the operating room. She did so only after praying first and asking God to guide her decision making on behalf of these patients. “He has always given me an answer,” she would tell me. “I can only do so much as a doctor, but ultimately a patient’s fate is in His hands.” She prayed before every case for God to guide her every action so that she would keep each patient safe. After whispering the mantra three times, she pressed the figurine against her forehead and then against her heart.

  “No prank calls,” she said right before leaving, referring to the time when I’d dialed random extensions out of boredom. “And don’t call the operator to page me. I’ll be back as soon as I can. Stay here and watch Scooby-Doo,” she said as she pulled back her thick black hair and stuffed it in one graceful swoop underneath her operating room cap.

  I climbed onto the hard call room bed atop an itchy frayed tan blanket that smelled like antiseptic, looking up at the blurry TV mounted on the sickly green wall. The alarm clock next to the bed blinked continuously in bright red numbers: 6:57 a.m. No photographs or decorations brightened the room; just a bed, a television, and a nightstand with a big brown and blue textbook titled in large gold letters: ANESTHESIA. We had been in the hospital with our mother so often that her call room had the familiarity of a relative’s home.

  My brother would become my best friend. As we grew up and graduated from afternoons in day care or my mother’s call room, we would become latchkey kids, taking care of each other in the hours we waited for our parents to return home from work. I’d warm bowls of frozen peas or make us macaroni and cheese from a blue box, and he’d force me to take a break from studying to watch Alvin and the Chipmunks with him. His sense of humor balanced out my intensity. Though we’d argue bitterly over the freedoms he was given instead of me—a car in high school, permission to stay out late without a curfew—I could be honest and vulnerable with him in a way I couldn’t with anyone else.

  My mother returned to check on us between cases, telling us about the patients she saw. She spoke excitedly, jumping from one incomplete strand of thought to another, talking about medicine as if my brother and I, mere grade-school children, were her colleagues. When I was in my own training years later, I’d realize that these stories weren’t just about medicine: they were about her trying to make sense of what she witnessed, grasping for words to articulate the moral and spiritual questions her work raised. She told us about a nineteen-year-old patient who died because cocaine constricted his arteries and his heart stopped. She had only been responsible for putting a tube down his throat and connecting him to a ventilator, but still found herself wondering why cocaine stopped his heart when using it hadn’t stopped the hearts of people older than him. She told us about the man with lung cancer who was diagnosed only because he was hit by a truck and taken to the hospital, where a routine chest X-ray revealed a bulky growth with jagged edges in his left lung. His lung cancer had been accidentally discovered early enough that the surgeons could cure his cancer just by removing the tumor. If he hadn’t been hit by that truck, my mother told us, the tumor would have silently spread to other organs, becoming incurable and taking his life. She told us about the woman in her twenties who delivered her first baby, a healthy boy, only to die an hour after his birth from a massive blood clot that traveled to her lungs, stopping her heart before she had a chance to name her son.

  My brother and I chewed the grilled cheese sandwiches she brought us from the cafeteria, looking at her as though she were a hero. I asked her why she couldn’t save the young mother.

  “Doctors aren’t God,” she told me. “We can only do our best to help people, but everything that happens is because of God’s plan.” I wanted to ask why a young mother’s death would be part of any plan, but my mother’s pager went off and she told us she’d have to leave. Years later, in my own training, I’d wonder if this was how my mother sought to find meaning in the tragedy she regularly encountered, if her faith was her parachute, her shock absorber.

  * * *

  I could guess what my mother would advise me about Mr. Tan’s situation: “Don’t get too attached. You can only give him the antibiotics and tell him there isn’t much more to do, and he should pray. And you should pray for him.” She would advise both compassion and distance, doing what was medically feasible and leaving the rest to God.

  But doing that didn’t come naturally to me. I’d always admired my parents’ strong spiritual beliefs, the way they offered every major life decision and attributed every success to God. I tried to do the same, but my efforts didn’t always feel genuine. My parents had clung to God to find a way to endure the circumstances of their respective childhoods. I went through the motions they considered sacred, mainly because I wanted to please them, but I didn’t experience divinity the way they did. We sat together singing devotional songs every Sunday and Thursday evening in the company of other Indian immigrants in our neighborhood. Because my parents believed that service to others was a form of worship, on Sunday mornings my brother and I would help them to make and distribute peanut butter and jelly sandwiches to homeless people in downtown Los Angeles and Long Beach. I did these things impatiently, waiting for my time to be my own again. While my parents emerged from prayer restored, I remained bored and irritated. Yet some part of me was envious of their spirituality, their ardent faith that since God oversaw their lives, there was no such thing as a good or bad event. That everything that happened was an intended part of a greater plan than they could understand, one they tried to accept with complete surrender.

  But I didn’t see how I could apply this to medicine, where I’d come to see prayer as a last resort. Would I pray to influence the outcome of Mr. Tan’s situation, or would I pray to help him find the strength to endure no matter what the outcome? Would I pray for guidance to care for Mr. Tan the right way? To bargain with God over Mr. Tan’s mortality? I couldn’t ignore the nagging feeling that I was running out of ways to fix Mr. Tan’s many problems. Maybe now was the time to pray.

  Three consecutive shrill beeps punctuat
ed the silence. I had to go to the emergency room to see several new patients. Hours later, on my way back to my call room, I stopped by to see Mr. Tan. He felt absent. He was there but not there, eyes overcast, a heaviness to his wave hello.

  “You seem down,” I said, and he shrugged but picked up his marker and whiteboard.

  I am scared. I don’t want to lose my family.

  I nodded, pulling up a chair next to his bed. He erased his board, which could fit only a couple of sentences at most, and wrote more: Noelle, she went to Davis after junior college. I nodded, and he erased and wrote more: Laura and I owned a restaurant. We cooked everything.

  Pointing at his feeding tube, he wrote: So this is hell.

  I nodded and winced internally, imagining the horror with which a former chef accommodated a feeding tube.

  I do all this for them.

  I started to feel the slightest bit uncomfortable, unsure what I would say once he stopped writing and erasing. He did stop, and he looked at me.

  “This must be so difficult for you to go through, Mr. Tan. Do you ever think about what you would want if we couldn’t get you better?”

  There. I tried. I said it. Imperfectly, and not as clearly as I had hoped. But I had tried.

  I will suffer if you give up on me, he wrote and erased. As long as I am with them, I will be OK.

  I peered intensely at his whiteboard, at each word as he wrote it, at each word that took its place. I had been thinking about how to talk to him about dying, but he was telling me instead about his life, about why he continued to live it despite his suffering, because to him the ultimate suffering would be losing his family. In the six months of my residency, I learned just how much pressure to apply when plunging a needle from the skin of the neck into a large vein just below the surface, leading to the heart. I learned how to place my finger inside a patient’s rectum until I felt the smooth surface of a healthy prostate or the knotted irregularities of a diseased one. I viewed a patient’s abdomen using an ultrasound, seeing the intestines floating in his natural juices and identifying where unnatural juices produced by a cancer had collected. But nothing felt more invasive, more intimate, than this exchange of words between Mr. Tan and me. With his words, Mr. Tan illuminated that cavernous resting place of his hopes, fears, and anxieties.