by Sunita Puri
Four
EXTRAORDINARY
San Francisco, Spring 2012
Six months after finishing my rotation in the ICU, I was nearing the end of my second year of residency. I had applied for and been accepted into a palliative care fellowship program at Stanford, which would begin just over a year later—after I finished my third and final year of residency. I’d been both relieved to have made a decision about my future specialty, and overjoyed that I’d be able to stay in the Bay Area. The acceptance letter from Stanford arrived over email one morning during my rotation at the veterans hospital in San Francisco, where I was overseeing two interns and a medical student. Our team was on call that morning, evaluating sick patients in the emergency room and admitting them to the hospital under our care. We had already admitted nine new patients by late morning, when I finally had a moment to read rather than skim my electronic acceptance letter. Just as soon as I’d read the letter through once and started to read it a second time to be completely sure that I wasn’t dreaming, my pager beeped, and off I went to the emergency room.
Mr. Smith was the tenth and last patient our team admitted to the hospital on that busy morning in mid-April. As was customary, the emergency room physician told me the details of a patient’s case so that I could make initial recommendations for his care and decide which unit in the hospital (the intensive care unit, the cardiac monitoring unit, or simply the main medical unit) Mr. Smith needed based on the severity of the illness. Deceptively simple sounding, this task drew upon several critical skills: identifying how dangerous the patient’s ailment currently was or could become; thinking about the most life-threatening and most likely diagnosis; integrating these possibilities with the physical examination of the patient; and coming up with a treatment plan.
The emergency room physician spoke quickly. “He’s got esophageal cancer that has spread throughout his liver and his lungs, and on top of that, now he has a huge blood clot in his lungs. The notes from his oncologist say he’s got a do-not-resuscitate order, but he’s disoriented and I can’t really get him to talk to me about his wishes. His labs are a mess, and his oxygen saturation is really low. He’s not looking good.”
“This does sound bad,” I responded. “Are you treating the clot with heparin?” I asked, referring to a powerful blood thinner given through an IV to treat blood clots.
“One of his notes says he had some kind of hemorrhage about a month ago, somewhere in his abdomen. No bleeding since, but if we start heparin, he might bleed again. Since you are admitting him, though, that decision is yours.”
Nice sidestep, I thought grimly, even though I recognized why he did so.
“And he’s totally out of it?” I asked.
“He’s so disoriented that he’s trying to eat his oxygen monitor.”
I headed to the emergency department to evaluate Mr. Smith, walking slowly to give myself time to think. He had incurable cancer of his esophagus that had spread to his liver and lungs. The blood clot in his lungs deprived him of essential oxygen and dangerously strained his heart. The clot was almost certainly caused by his cancer. The dilemma he presented was both typical and acute: heparin wouldn’t dissolve the blood clot he currently had, but it could prevent another blood clot from forming and worsening the strain on his heart and lungs, killing him. But with heparin, given his recent abdominal bleeding, he was at high risk for a fatal bleed.
People with cancer often die of blood clots, I told myself. Is he dying? My own question scared me. Even though I had nearly completed two years of residency training, had a license to practice medicine in California, and had been accepted into a fellowship in palliative medicine, I doubted my ability to determine whether a patient’s malady was a natural part of the dying process or just another problem to be fixed. Dennis came to mind: A ventilator and dialysis assumed the work of his failing lungs and kidneys. He needed powerful medications to help him maintain a normal blood pressure. His muscles withered away from lack of use, and his gut couldn’t absorb the artificial nutrition we gave him through a tube in his nose. We’d all acknowledged he wasn’t getting better. But was Dennis dying? This wasn’t a question we had asked ourselves until his wife pushed us to consider his suffering.
Why am I so afraid to acknowledge that Mr. Smith might be dying? I wondered, puzzled. I’d been far more comfortable wondering about Mr. Tan’s mortality, even though what I’d heard of Mr. Smith suggested he was closer to the end of his life. Yet when I imagined forgoing treating Mr. Smith’s clot, I felt ashamed. The impulse to keep a patient alive was deeply ingrained, I realized. We as physicians in training were impelled to prolong life, enable survival. We hadn’t become doctors to recognize and accept dying.
The culture of American medicine focused mainly on saving or extending lives. New medications studied in medical journals were evaluated for their “survival benefit,” the additional months or years they could add to a patient’s life. Most departments hosted weekly or monthly “Morbidity and Mortality” conferences to discuss among colleagues why certain patients died, and whether they could have survived if only their care had been handled differently. Medical professionals and the public alike were socialized to believe that saving lives was medicine’s mission, as a seemingly endless string of medical television dramas and movies suggested. And if patient deaths represented medicine’s failures, I thought, then it shouldn’t surprise me that we struggled immensely to identify, name, and discuss anything other than survival.
What did surprise me was that my impulse toward intervention seemed to have strengthened after my ICU rotation, particularly when I was in charge of a team including two interns and a medical student. As a senior resident, my job was to see all of the patients admitted to our team, but also to teach the interns and medical students how to develop a plan of care for each patient’s condition. I was still in my training, but also now teaching and leading. And though I couldn’t explain why, I felt pressure to model the type of doctoring I’d often questioned as an intern. If a patient was in the hospital, there must be some intervention I could offer, some problem I could fix. I recognized that I could do harm trying something, anything, to fix what was wrong. But it was one thing to know this and another to act on this impulse, especially when I was charged with treating patients and teaching younger colleagues.
I can’t let him die, I thought to myself. He’s got cancer and a related blood clot. I’ve treated so many blood clots. It would be easy to treat this one.
Hold on, said another voice, something deeper, calm and firm.
Go see him first.
* * *
Mr. Smith’s room was dark except for the green glow of his heart monitor and the flash of a red alarm, drawing my attention to worrisome vital signs: an abnormally rapid heart rate in the 120s, low blood pressure in the 90s, and a dangerously low blood oxygen saturation in the mid-80s. Collectively, these numbers indicated that his lungs and heart were failing as a result of his blood clot. I pressed a button to silence the alarm and heard a broken voice. “Darlene, Darlene, Darlene,” he murmured.
“Mr. Smith?” I said, hesitantly.
“Daaarrrleeeeeene,” he responded, his voice stronger.
I began to examine him. Tangles of matted brown hair framed his fragile face. Deep wrinkles gathered at the corners of his eyes. His ribs protruded like speedbumps along the narrow path of his torso, leading to a concave belly. EKG leads, oxygen tubing, and three intravenous lines tethered him to his bed. His skin was covered with bruises from multiple attempts at blood draws. A white device was taped around the first finger of his left hand, monitoring the amount of oxygen in his blood. He gnawed on it and stared past me. On his right arm, I saw serpentine veins, the pull of flesh against bone, a faded green tattoo of the sort I had seen on many military veterans. It read, “Where there is light there must be darkness.”
I listened to his heart, a flutter in the great hollow of his
chest. His breath was shallow and quick, a distant whisper. He coughed when he tried to swallow, his saliva unable to slither around the tumor in his esophagus. His body told me a story that he couldn’t tell me. His chart filled in a crucial detail.
“Patient would not want extraordinary measures,” his most recent oncology note said. “No known family or friends. Cannot name a decision maker. Code status: DNR/DNI.” This meant that if his heart stopped and he died, he would not want us to resuscitate him by performing CPR or delivering an electric shock to his heart. He would not want to be intubated and placed on a ventilator if he couldn’t breathe. He instead wanted us to allow him a natural death.
I looked at his CT scan. It was difficult to tell where he ended and where his cancer began. Tumors glowed throughout his body like a macabre Christmas tree.
Giving anticoagulants for blood clots isn’t an extraordinary measure, my textbook voice said. It is possibly one of the most ordinary things I do in internal medicine. But, my deeper voice inquired, is treating his blood clot extraordinary? That is a different question. He could bleed and suffer more than he is currently. He also might not bleed. Would that result in a better life, or a more drawn-out death? None of the 2,500 notes in his electronic chart provided any answers. The only documentation that really told me anything about his perspective on life was his tattoo: Where there is light there must be darkness.
I called his oncologist, his internist, and his nursing home, looking desperately for guidance, and possibly also for someone to validate my impulse to treat the blood clot. Nobody could give me the information I needed: Who was this man? What did he know about his cancer? What quality of life did he value? Is there anyone else I should try to reach? The answers I got were almost always speculative. Only one staff member at his nursing home could tell me something with certainty: “All I know is that he always asks for root beer, but he can’t swallow it because he coughs. It makes him happy, though.”
And so I remained exactly where I started, looking at the sweetly disoriented man before me, wondering whether to place him on an oxygen mask that would fit tightly across his face, treat him with heparin and risk causing him to bleed, or get him back to the nursing home with hospice services the next morning to keep him free of pain and shortness of breath during his final days. Perhaps what I could offer him most urgently was pausing to think clearly about the best way to care for him. I didn’t want to cause him suffering, but I also felt an obligation to treat the problem that brought him to the hospital.
* * *
On afternoon rounds, I sat down with my attending physician, Dr. Doyle, our intern, Ryan, and our medical student, Erin, to discuss the patients whom we had just admitted to the hospital, so that each patient had a clearly defined plan before I settled in, alone, to care for them overnight. We discussed Mr. Smith first.
Ryan and Erin had both evaluated him in the emergency department after I did. Ryan’s role as an intern was to come up with a plan to treat Mr. Smith, and my role was to listen to and critique his plan, particularly if I disagreed with it. Ryan wanted to give him heparin for his blood clot and intravenous fluids to bring down his blood calcium level, which was elevated because of his cancer and which could have contributed to his confusion. Ryan hoped that, if Mr. Smith became less confused, he might be able to tell us exactly what he wanted for himself. If we tried his plan, we would draw Mr. Smith’s blood multiple times per day (to make sure that his blood was sufficiently but not excessively thin), run several liters’ worth of IV fluids rapidly through his arm (to bring down his blood calcium level), and strap a plastic mask around the bridge of his nose and his mouth, connecting him to a machine that helped him to breathe but without a tube in his throat. Ryan wondered whether physical restraints would be a good idea, since during his hours in the emergency department Mr. Smith had removed his breathing mask several times. Also, Erin piped up, perhaps there was a way to tape the mask to Mr. Smith’s skin, since even the smallest adult-sized mask available couldn’t conform to his angular, narrow face.
Their plan was stunningly comprehensive. If Mr. Smith died in spite of these valiant efforts, at least I would know that we had left no stone unturned, that we had tried everything possible to keep him alive. Yet I felt a stab in my gut as I imagined Mr. Smith tied to his bed, his oxygen mask pressing into the delicate skin of his nose and cheeks, plastic bags filled with cold saline running through the veins we would pierce throughout the night to draw blood. None of this would take away his advanced cancer, I reminded myself. But what if it bought him a few more days at his nursing home, less confused and breathing easily?
“Thanks for this thoughtful plan,” I began. “It sounds like you want to give fluids for the calcium level and heparin for the blood clot so that you can hopefully hear from him directly what he wants in this situation.”
“Yes,” Ryan said, nodding. “I mean, we considered that he could bleed because of the heparin, but if that happens we could always send him to the ICU and stabilize him with blood transfusions and maybe an endoscopy.”
“Sure, we could . . . ,” I began slowly, then paused. Sure, we could always send him to the ICU in case he bled, but shouldn’t we seek to avoid that scenario in someone this fragile? Why was I even entertaining the option of giving him heparin when he had bled so recently? Yes, Mr. Smith had been brought to the hospital because he couldn’t breathe, and, as a doctor, I was supposed to fix the problem. But you can’t make decisions about his treatment to make yourself feel like a “good doctor.” The same voice that encouraged me to see Mr. Smith before deciding what to do for him reminded me that what I could theoretically do for him wasn’t necessarily what I should do for him.
“Do you think that he is this confused because he is dying?” I asked Ryan and Erin, trying my best to channel the calm with which Dr. McCormick had asked me that question about a patient we’d seen together more than two years ago.
Erin looked at me, surprised. Is this a trick question? Ryan glanced at the pages he had printed from Mr. Smith’s medical records, the results of his blood tests, his CT scans, his oncology clinic notes, and said, “I still think there’s a way for us to get him more oriented so that we can hear from him what he wants us to do.”
“Yes, but what if the reason he is so disoriented is because his body is shutting down from his cancer?” I was talking to myself as much as I was talking to Ryan and Erin. How much were we willing to do to Mr. Smith to see if we could “get him more oriented”? If his blood oxygen dropped to more dangerous levels and rendered him too sedated to breathe on his own, would we override his do-not-intubate order, place him on a ventilator, and send him to the intensive care unit? Even if Mr. Smith “got more oriented,” I thought to myself, what options can we offer him? Treating his clot but risking a large bleed? Was it fair to “hear from him what he wants us to do” if all we could ultimately do is keep him free of pain, anxiety, and difficulty breathing as he goes through the dying process?
“Don’t we still have to treat the blood clot, though?” Ryan asked. “Yes, he’s going to die from his cancer because we can’t treat the cancer, but shouldn’t we still try to fix what we can?” Yes, but what if trying to fix him kills him? I thought. My whole team stared at me. Ryan and Erin observed my decision-making process, Dr. Doyle studied my teaching skills and medical knowledge, and our pharmacist waited to tell me what dose of heparin to give Mr. Smith if that was how I chose to treat him. I felt as though they could sense my unacceptable uncertainty, that its scent overpowered the stench of hand sanitizer and stale potato chips that filled the hospital.
“This is a very tough situation,” Dr. Doyle said, breaking the brief silence. “He’s already on some fluids and sounds like he is somewhat stable right now on the mask, so you have some time to think about what is really the best plan for him.” I wished that Dr. Doyle would just tell me what to do. But he often didn’t. “You’re going to be an attending in just
over a year,” he’d told me when we initially met each other and discussed his expectations of me during the month we’d work together. “You have to learn to make decisions as though I’m not here. And you have to trust that if you are making dangerous or poorly thought out decisions, I am going to tell you.” He had a shock of white hair and a kind, slim face. Believing him meant believing in my own judgment, which was sometimes a challenge.
As we went over the plans for the other nine patients we’d admitted, my mind kept drifting back to Mr. Smith. Several other patients were far sicker than he was, one suffering from severe liver failure and another from a heart attack, one from end-stage dementia and an infected bedsore, another from a kidney infection and severe diabetes. But although several were so tenuous that they might soon require ICU-level care, I felt confident rather than conflicted about my plan for each of them. Their treatments came with risks, as all medical treatment plans do, but the risks paled in comparison with the very clear benefits.
After rounds, I stared at the computer screen intently, as though the intensity of my stare could produce the clarity of the right answer. It was second nature for me to treat a blood clot, and my fingers started to fill out the order set. I made it halfway through, then pressed Delete. I started it again, then paused. Looked at the screen. Pursed my lips. I still felt the weight of Ryan’s and Erin’s confused stares. Was I a fraudulent physician because I wanted to forgo treating a blood clot? Because I thought treating a blood clot wasn’t necessarily treating Mr. Smith?
With trepidation, I called Dr. Doyle and told him that even though it would be very easy to try giving Mr. Smith heparin for his blood clot and liters of saline to treat his high calcium, ultimately both were clear signs of his body dying from cancer. To halt that natural process, especially with heparin, would risk severe bleeding that would only worsen his suffering. “Even if he did wake up,” I said, “we would not be able to offer him options aside from hospice, so perhaps it’s best to keep him comfortable and not do anything risky. I just think he’s dying.” Silence followed. I wondered if Dr. Doyle was about to tell me that he had serious concerns about my decision making, that he wondered if I was really ready to move on to my third and final year of residency.
