That Good Night

by Sunita Puri

  When patients’ lungs filled with fluid—due most often to heart failure or to advanced cancer—I learned to cut the skin on patients’ backs and use a catheter to drain the fluid, quickly easing their shortness of breath. I pierced the skin of other patients’ necks and threaded catheters through the veiny highway leading directly to the heart so that I could give them medications too powerful to be given through a regular IV. I threaded larger catheters called pulmonary artery catheters from their necks into their hearts, through the right atrium and the right ventricle all the way into the entrance of the pulmonary artery.

  Sometimes the heart reacted to the foreign catheter by fluttering in a dangerous pattern called ectopy. “Did you watch for ectopy when you advanced the catheter?” my mother asked me the first time I placed a pulmonary artery catheter.

  “Yes, I saw it. I was so scared for a second,” I replied, remembering my anxiety as I watched the patient’s heartbeat become erratic as the catheter advanced and irritated the heart.

  “I used to put them in every patient before they went to the operating room,” my mother replied, adding, “Now you know how long each one of those procedures takes. That’s why I left home so early for so many years.”

  I suddenly saw myself at four, clinging to my mother’s leg, begging her not to go to work. My father would pull me off her and hold me as I cried, watching her disappear quickly through our front door without looking back. I saw myself at seven in a trailer behind our elementary school stuck for hours in the after-school care program for children with working parents. It was Friday, and I overheard the two women in charge whisper to themselves that my mother was late, yet again. It had been an hour since the last child was picked up. I pretended not to hear them, instead focusing my attention on the herculean task of trying to play Hungry Hungry Hippos alone. My face burned with embarrassment, then with anger. Where was my mother? She eventually showed up, running from her car to the trailer, unaware that she’d forgotten to remove the blue operating room cap that still covered her hair. “You’re not in the hospital anymore,” I told her angrily as I pointed to her head and pushed her away when she tried to hug me.

  She was late because she had been doing the things I was learning now. I could understand her absence. In the quieter moments of my ICU rotation, I marveled that she’d made time for anything other than work and her own survival during her residency.

  I quietly celebrated the success stories of some people I treated in the ICU. These were people who needed only a few days’ worth of machines and medications until their severe infections abated or the unexpected complications of surgery resolved. They persevered through painful but necessary procedures, and endured the disruptive noises and tense atmosphere of the ICU that left them disoriented and sleep deprived. The payoff for their discomfort was surviving and going home. It was incredibly satisfying to care for patients who survived, and upsetting to lose those whose illnesses outsmarted our best lifesaving efforts and technologies. But it was outright troubling to care for the patients who neither survived nor died. These were people who might remain in the ICU for weeks or months, their hearts and lungs and kidneys stuck in a cycle of incremental improvements and sudden setbacks. I treated these patients with the same care as every other patient, but doing so set off a slow burn of unease: No matter what I did, they remained gravely ill. Sometimes, the more I did to them, the sicker they became.

  Dennis was a retired businessman in his sixties whose lungs began to fail shortly after undergoing surgery for a broken hip. His lung failure caused his heart to fail, and we tried every possible medication to manipulate his heart’s physiology, prodding it unsuccessfully toward healing. Fluid from his failing heart began to fill his lungs, which required more and more support from the ventilator until there was no more support to give. As his heart and lungs deteriorated, his kidneys shut down, so we started dialysis. Because we could. Because that’s what you do when your patient’s kidneys start to fail. But is it what you do when kidneys start to fail because other organs are failing and aren’t getting better? I asked myself, though I never voiced my concern on rounds with my team. The pace of the days left me breathless and unable to focus on anything other than performing procedures, ordering medications, and manipulating machines to keep each patient alive. Yet as I outlined my treatment plan for Dennis in the daily notes I wrote in his chart, I wondered whether anything I’d done for Dennis had actually helped him to get better. I had intubated him, attached him to a ventilator, placed a pulmonary artery catheter into his heart to monitor its function, requested the expert opinions of cardiologists and nephrologists and infectious disease physicians about his care. I had done everything that my mother would have done for Dennis. But I wondered if the life I sustained for him was one he would find acceptable. He could not speak or eat. He couldn’t recognize or interact with his wife and son because of the chemical haze of pain medications and sedatives he needed to tolerate being pinned in place by the tubing and needles that connected him to monitors and machines. As his days in the ICU turned into weeks, I began to suspect his losses weren’t temporary ones. I continued to hope that he would recover, though I couldn’t exactly envision what recovery might look like for him.

  One afternoon, I sat with Dennis’s wife, a thin woman who wore matching turquoise and silver earrings and bracelets. I told her that even with the maximum possible support from the ventilator, Dennis’s blood oxygen saturation hovered around 85 percent, far from the normal range of 92 to 100 percent. I told her I worried about the extent to which his low blood oxygen levels had damaged his brain and his heart. I explained that I would order another CT scan of his lungs to assess for any new injury they might have suffered. If fluid had once again accumulated in his lungs, I could insert a needle to remove it and help improve his oxygen levels.

  Dennis’s medication pump began to beep, signaling that one of his medications needed to be refilled. I fumbled with the buttons on the pump, trying to silence it. “Do you think he’s suffering?” his wife asked me as she stroked his hair, matted and greasy after three weeks in the ICU. His face, now rough with salt-and-pepper stubble, was doughy and ruddy, his once sharply defined features now swollen with the fluid his heart and kidneys could no longer manage, even with the help of our machines. Yet even though he scarcely resembled himself, he didn’t appear to be suffering: he was sedated, seemingly unaware of being attached to devices that enabled us to support his ailing heart, breathe on behalf of his lungs, and clean his blood since his kidneys could not. “I don’t think he is in any pain because we are giving him medications to keep him comfortable,” I said gingerly, “but I think that going through all of these treatments and not being able to live his normal life has got to be very hard on him.” She nodded, her eyes darting between his face and the ventilator and the gray monitor that hovered above him, capturing the rainbow of his physiology: The green line of his heart rate and rhythm. The red line of his blood pressure. The white line of the percentage of oxygen in his blood. The yellow line indicating the pressure in his pulmonary artery. I watched Dennis’s monitor more closely than I had ever watched him.

  It occurred to me later that evening that when I gave Dennis’s wife updates about his condition, I spent more time explaining how I would address his health problems than I did explaining their significance. I was quick to offer next steps and treatment strategies without explaining that each setback—a bladder infection, or worsening heart failure, or a pneumonia caused by being on the ventilator for too long—made hope for recovery an even more distant twinkle on a dark horizon. I felt ashamed as I remembered describing to her the next steps in Dennis’s care that I’d discussed with my attending on morning rounds; by only discussing next steps, I might have also offered false assurance that his persistently low oxygen saturation might be fixable.

  If I could redo this conversation, I would have asked Dennis’s wife what prompted her to ask that question, whether sh
e observed Dennis to be suffering. I’d ask her how Dennis himself might define suffering in this situation. I wondered about the suffering he might have experienced because of our well-intentioned efforts to treat him. What must it have been like for him to be unable to live without the support of machines, and unable to die because of the support of machines? Perhaps what I could offer him most urgently was pausing to think clearly about what would truly help rather than harm him. I did not want to expedite his death, but I also did not want to commit him to that hazy purgatory of being alive but not necessarily enjoying the quality of life he might value. I had seen that before in my teenage years, when I met Rajiv.

  Los Angeles, 1994

  Just past the entrance of a place I’ll call Bright Clouds Nursing Home, a red-haired nurse in lavender scrubs waved hello to my father and me and motioned us to go on ahead past the front desk. I held my breath as I stepped through the foyer, bracing myself for the usual putrid mix of urine, bleach, and a faintly floral air freshener. Around the cluster of tables in the dining room sat the same people in the same places: A frail, ghostly man swaddled in a fluffy blue blanket, his head slumped forward and mouth agape. Next to him, a woman whose hairline began midway down her skull and who made continual smacking motions with her lips and occasionally screamed. A man, who I guessed was around my father’s age, walked around these two to get a fruit cup, though he seemed to waddle with an unusually wide space between his feet and carried a bag next to his leg, filled with what I would later realize was his urine.

  This was a place with a large, empty guest parking lot.

  The December cafeteria menu hung on the wall above the ghostly man and the screaming woman, the daily staples of pancakes, sandwiches, and pastries written in red and green ink. Off to the side, a Christmas tree sagged under the weight of too many silver ornaments and twinkling lights. Brightly wrapped boxes were arranged at its base, and I wondered whether those were real gifts or decorations. Overhead, music from the 1940s and 1950s played.

  This was my third visit to Bright Clouds. My parents were horrified by the very concept of a care facility for the elderly, who they believed should be cared for by family, not strangers. They were especially horrified that some Bright Clouds residents had no family, or had family who never visited them. Throughout middle school and the beginning of high school, I reluctantly tagged along with my parents as they brought Christmas gifts and Easter baskets to residents without families. Though they didn’t practice Christianity, my parents nonetheless considered Christmas and Easter to be holy days that should be spent with family. Visiting Bright Clouds was one of many quiet community service projects that my parents voluntarily adopted. They reminded my brother and me constantly that service to others—particularly society’s most vulnerable—was an act of worship. Though I was a sullen adolescent, I agreed with my father, but wished for a community service project anywhere other than Bright Clouds. I groaned when he would place a bag of gifts, wrapping paper left over from last Christmas, and tape in front of me. “Take care of this,” he would tell me. “Then we will go to Bright Clouds.”

  The combination of the residents’ debility and the isolation at Bright Clouds overwhelmed me. I smiled and shook their hands as my father instructed, trying to suppress a mix of tears, nervous laughter, and a strong impulse to run away. Once, I excused myself to go to the bathroom while my father distributed gifts to a demented lady who babbled softly, a gentleman whose legs had been amputated, and a very old lady with severe scoliosis who had told him that she wished she could see the sky again. I would occasionally cry on our rides home. My father offered no solace. “Growing old and getting sick is all part of life,” he would tell me. “You should learn this now. We will all grow old, and one day we will all die, too.” I would ask my father why he told me this every time we drove home from Bright Clouds, why we couldn’t instead just stop at McDonald’s for an apple pie and soft serve and put the afternoon behind us. Why did we have to talk about such sad things? Why did we have to go back to this sad place on happy holidays each year?

  “This is part of life,” he would repeat. “And some of these people are in very sad situations on days when you and I and so many others are enjoying ourselves. So why not spend some time bringing them some happiness when they are clearly suffering?”

  My father knew a few things about suffering. The youngest of seven children, he grew up in Darya Ganj, a district in Delhi that my father remembered fondly for the few things he enjoyed as a child: sticky orange jalebi and milky chai, a rare outing to Golcha Cinema, and narrow, interconnected alleys where he would hide from his mother and play cricket with friends from school. From the rooftops of apartment complexes, he would fly kites he’d made himself from paper and string, lying down to sleep on these same rooftops when summer arrived. Gazing at his neighborhood from this vantage point, he observed that suffering was inescapable because he saw it everywhere: the lepers who had so little that they begged the poorest families for scraps from dinner, an apartment complex filled with women who had been raped in the violence of Partition, only to be abandoned or rejected by their families. And he saw the suffering of his own mother, whose rheumatoid arthritis was so severe that my father came straight home from elementary school to help prepare the family dinner. He’d mix together flour and water into a doughy paste and make oddly shaped chapattis with his tiny hands. Since my grandfather could never seem to keep a job, my father devised his own ways to help my grandmother buy food for dinner. He began to play marbles with local children and would bring home the prize money he won in street tournaments. Occasionally, he’d even trek to wealthier areas and clandestinely attend weddings. When guests threw money at the bride and groom after the ceremony ended, my father would grab as many rupees as he could and race home.

  Witnessing her suffering was unbearable for my father. He prayed to God to give him his mother’s arthritis; it would be easier to have the arthritis himself than to bear witness as she endured it. “But this is my share of suffering,” my grandmother would tell him when he shared his prayer with her. “This is my luck, not yours. You cannot suffer for me.”

  “So you couldn’t fix Dadiji’s suffering,” I would say, though in retrospect I’m not sure if I was making an observation or asking a question.

  “No,” my father acknowledged. “But I had to learn that a part of lessening her suffering was just seeing that she was suffering, and doing what I could to help her.” My father didn’t speak of suffering as something to lament or avoid. He spoke about it as part of being human, as something we all had the power to endure, even transcend. Suffering didn’t preclude survival.

  As we left Bright Clouds that afternoon, my father noticed an elderly Indian gentleman in the foyer. We had never seen him, or any other Indians, in the years we’d visited Bright Clouds.

  And yet here was Bajwa Ji, standing in high-waisted pants with a tightly bound belt, white shirt, and thick glasses that reminded me of my father’s. He clasped his hands behind his back as he walked, just like my father did. He had the tired, overwhelmed eyes of someone perpetually displaced. My father immediately began speaking to him in Hindi, startling Bajwa Ji.

  Namaste, Ji. Kii haal hai?

  We quickly learned that he was from Delhi, and that his forty-eight-year-old son, Rajiv, had been in a car accident in Los Angeles about five months before, leaving him in a permanent vegetative state. Rajiv’s wife and children left him after the accident, and the only place he could be properly cared for was at a nursing home like Bright Clouds. Bajwa Ji and his wife, Amita, both in their early seventies, moved from Delhi to a small apartment near the nursing home and spent every day and many nights at his bedside, hoping that God would reward their vigil with the miracle of Rajiv talking, thinking, walking, eating, and returning to his former self. Both Bajwa Ji and my father wondered how they hadn’t crossed paths before at Bright Clouds. I cringed, realizing that our visits to Bright Clouds wou
ld now become more frequent.

  Rajiv’s room was on the right side of a long gray hallway. He was the only Indian patient the nursing home had ever had, according to the red-haired nurse, who told us that the orderlies and nursing assistants had comforted him in Spanish, assuming that he was Latino. Rajiv lay in his bed, eyes wide, brow wrinkled, wearing an expression of permanent surprise. I wondered if this was how terror twisted his face when he first saw the oncoming car, when he tried unsuccessfully to swerve out of its way, when he heard the crunch of metal on metal, suddenly airborne and then amid concrete and shattered glass. He always wore a white gown, white sheets covering him, as though he awaited cremation at a Hindu funeral.

  I was expressionless during these visits, watching as nurses gave him a sponge bath, carefully lifting and moving his stiffened limbs, offering soothing words when he flinched in pain. They refilled his feeding tube formula, took his blood pressure and temperature every few hours, emptied the plastic bag that collected his urine, changed the diapers that collected his waste. His mother sat next to him, helping the nurses when she could, smearing holy ash on his forehead and whispering prayers. She wore brightly patterned saris, collages of burgundy, marigold, and emerald, bringing warmth to Rajiv’s sterile room.

  He’s a living dead man, I remember thinking in my sullen teenage way.

  Bajwa Ji began to call our home frequently, quietly saying, in Hindi, “Beta, me Bajwa huu.” Child, I am Bajwa.

  He never had to tell me that he was looking for my father. My father never had to tell me to interrupt whatever he was doing to speak to Bajwa Ji. I hovered outside my father’s office, observing the long stretches of silence as he listened to Bajwa Ji, telling him that he shouldn’t cry, that God certainly heard his prayers, that God could do anything, including healing Rajiv. I wondered if my father believed what he said, and how exactly he thought Rajiv would “get better.” It was miraculous that he had survived, he would tell Bajwa Ji. Perhaps he needed to remember that, by remembering God, another miracle could take place. “Sometimes, God tests us,” my father told me. “Believing in the impossible is a part of having faith.” But, I later wondered, isn’t accepting the unbearable also part of having faith?