That Good Night

by Sunita Puri

  “Fighting means overcoming,” Teresa said. “It means keeping going no matter what the circumstance. He is fighting for his life. I see it every time he kind of shakes in the bed.”

  “He is fighting a very tough battle,” I said. “Winning the battle would mean that he wakes up and goes back to his normal life, correct?”

  “Yes,” Teresa said. “And I know that is going to happen.”

  “You’ve mentioned that he would want everything done for him so that he can win this battle, and I think it’s important that you know everything possible is already being done right now. But the breathing machine and feeding tube can do only so much. For him to go back to his normal life, his brain needs to start waking up. It has been so badly damaged that he may never wake up. So we need to talk about what we should do if doing everything for him doesn’t seem to be helping his brain fight and get better.” I raced through my sentences, hoping they’d let me finish.

  “So what are you saying?” Teresa asked, exasperated.

  “You’ve given me a sense of who your father is as a person, as someone who would fight tooth and nail to get better. But we are seeing that, no matter what we do to support him, his body may not be able to fight the way he would want to. And while we can have hope that his body may recover, we also need to talk about what we should do if it continues to get sicker, which seems to be the more likely outcome.” Teresa and Ray remained quiet, which made me nervous. I kept talking.

  “We all want to see your father get better. But we all need to be on the same page about what ‘better’ really means. In his situation, there’s a chance that, at best, he would need to live in a nursing home on a breathing machine for the rest of his life. He might be okay with that. But if you think he wouldn’t want that for himself, we can talk about another option, which is to focus on keeping him comfortable and free of pain without the support of machines, and allow him to pass away.”

  The invisible hand returned, and I pushed against it to breathe. That was the first time I’d been able to say the words I’d been holding in—that there was another way to care for Joe if our default plan, continuing all current support, wouldn’t be what he’d want if he heard what his life would likely be like. In the brief silence that followed, I braced myself for the fallout.

  “Are you saying it would be better if we just unplugged him and let him go? Not give him every chance to fight? I don’t know why I need to keep repeating myself,” Teresa said, looking incredulously at her brother. “Here’s what you are all going to do. You’re going to fix the mistakes you made. You are going to do everything for my father. You asked me last time what my goal was? We expect him to be given every medical treatment known to man and he better be able to go home.”

  Just as I drew in a breath to respond, to use different words to re-explain the complexity of her father’s condition and the exceedingly low chance that he would recover even if we “did everything,” she pointed at me and began to speak. “And I am not interested in hearing you ask any more questions about what he wants if this or that happens. I don’t know how else to get through to you. Ray and I want everything done. E-ver-y-thing.”

  I wished I could understand what they saw when they looked at Joe. Did they see the father they loved? Did they really believe that his twitches were his attempts to move? Did they think that his eyes, glassy and vacant, saw and recognized them?

  I had been looking at Teresa, but glanced at Ray just then. He appeared to be holding his phone upward, as though he were making a video. I blinked, stunned by what I saw. “Are you recording this conversation?” I said in a voice I didn’t recognize, a panicked mixture of shock and dismay. “I’m going to have to ask you to stop. We don’t allow that.”

  “Why not?” Ray said, looking at me only through his phone screen, his expression an angry sneer. “You’re probably afraid because if I post this online and the world can hear what you are all saying to us, then you’ll think twice about treating anyone’s family this way. You people are crazy if you think we’re going to let you talk us into this, whatever, comfort bullshit because YOU’RE THE ONES WHO SCREWED UP!” He began to yell. I looked at Dr. Coffey, guessing that he would be okay with me wrapping up the meeting at this point.

  But before either of us could respond, Teresa and Ray began speaking to each other in Spanish, a language they didn’t realize I spoke and understood. Teresa told Ray that their father was in the hands of stupid doctors. Ray responded by wondering whether we were ashamed of ourselves for how we’d cared for his father. They exchanged a few thoughts about how they might use the small stretch of video footage Ray had captured. When I heard Teresa mention hiring a lawyer, I spoke.

  “Yo hablo español y puedo comprender todo lo que ustedes están diciendo,” I said quietly. I speak Spanish and I can understand everything you are saying. They stared at me, briefly quiet, until Ray told me he was glad that I heard they thought we were terrible doctors who deserved to be sued.

  “You know, I think we’re done here,” Dr. Coffey said decisively. “I don’t think that this is a productive conversation, even though Dr. Puri and I are trying our best to help your father. If we can’t talk about this, then I think I may need to call someone from our hospital’s ethics board to speak with you further.”

  “How many conversations are you going to make us have?” Ray said. “Haven’t we been crystal clear with you?”

  “I don’t think there is any point in continuing this discussion,” Dr. Coffey said again, signaling to me that we should leave the room. As we walked back to the ICU, he told me he suspected that Teresa and Ray might not actually be representing what Joe himself might want in this situation, instead ordering us to do what they want. “That isn’t the role of a surrogate decision maker, as you know,” he said. “It’s always to tell us what the patient himself would want.” Theoretically, this was true. But reality was complex; a grieving child could easily convince herself that her father would agree to an intervention that she might want for him. In the face of death, love and fear made porous the very boundaries we hoped families would respect. “I know that wasn’t a fun meeting. But thanks for being there with me. I would have given up and walked out long before if you weren’t there,” he said.

  * * *

  It was raining when I drove home that evening, the roads slick and the traffic formidable. I admired the water on my windshield, the way it caught the red of brake lights and the bright stream of headlights coursing by on my left. I half listened to the mindless mix of pop on the radio and the rhythmic swipes of my windshield wipers. I was exhausted, partly from the meeting with Teresa and Ray and partly from the sheer logistics of spending half of my days in the hospital and the other half doing home visits. Numbers mattered in new ways: The strength and effectiveness of our service was measured by how many patients we saw. But the more patients we saw, the less time I could devote to each person. My conversations with patients and families became more compact and, occasionally, incomplete. I felt forced to rush through discussions that required focus and care. This was a different exhaustion from what I’d experienced in residency and fellowship; those years had been an endurance test from which I emerged fatigued, but not depleted, the way I’d felt recently.

  I thought back to a conversation I’d had a few weeks ago with a colleague, the director of a palliative medicine program at the University of Southern California. She and I had met the year before at a conference and had kept in touch in the months after I moved back to Los Angeles. I may have a job opening up in a few months, she’d called to tell me. I think it could be a great fit for you. Lots of teaching opportunities with medical students and residents, and very interesting patients. I’ll keep you posted about what happens. I hadn’t been looking to leave my job, but her call made me remember what I missed about being at a university: Being in the company of other learners, teaching others and being taught, taking in noontime lectures b
y experts in lung cancer or coronary artery disease or geriatrics. I missed working with residents and medical students. Back then, I’d had not only the opportunity to teach them how to care for a patient but also the chance to debrief with them about the tough situations we encountered.

  But though I’d considered staying on as an attending at a university, I was drawn strongly to the idea of working at the same medical group that had employed my mother. Even when my days were tedious, I took unexpected comfort and pride in having followed my mother here. I was secretly overjoyed when a patient mentioned that she’d called my mother’s office instead of mine, or when I received emails intended for my mother. But eight months in, I wasn’t sure that this connection was reason enough to stay.

  * * *

  When I returned to work on Monday morning, I learned that Joe had died.

  At eight o’clock on Friday night, a few hours after the end of the family meeting, his blood pressure began to fall: 120, 100, 80, 75, 50.

  During the weeks he had been in the hospital, nothing had changed in his condition, until, over the span of thirty minutes, everything had. Dr. Coffey had returned from the family meeting to find Mr. Brown sweating from a new fever, his percentage of blood oxygen lower than normal. An X-ray of his chest revealed a new pneumonia that hadn’t been on the morning chest X-ray hours ago. His blood pressure dropped as his infection bloomed. When Dr. Coffey told Teresa that her father’s kidneys were also starting to fail, Teresa asked the nurse to call the kidney doctors so that Teresa could speak to them directly and make sure that Dr. Coffey was telling her the truth.

  4, 10, 25, 30. The dose of one of the medications to sustain his blood pressure increased rapidly over those thirty minutes. His blood pressure continued to fall even at the maximum dose. A second blood pressure medication was added. 5, 10, 20, 30. The dose rose as his blood pressure fell, a rising arpeggio and a falling one, each with a certain macabre grace, ending in silence.

  Around 10:30 p.m., Mr. Brown’s heart slowed and then stopped.

  Dr. Coffey led the effort to resuscitate him, ordering one of the nurses to begin chest compressions, to try to force life back into Mr. Brown’s dying body. The nurse pushed into his chest two inches deep, one hundred times a minute, for two minutes at a time.

  Teresa and Ray were pushed outside his room, forced back by the crowd of doctors, nurses, and respiratory therapists and pharmacists who hovered around his bed, each charged with the task of doing everything. The crash cart, a cream-colored vessel containing all of the medications and tools needed during a Code Blue, took its place at the rear of the room. There was no space for the two people Joe had probably wanted at his side.

  Everything. The 30 and 30 and the 100 compressions per minute, each deep into his chest.

  “10 rounds of CPR were performed,” Dr. Coffey wrote. “No return of spontaneous circulation.” No heartbeat despite the compressions, the 30 and 30.

  I wondered what I could have done differently in talking with Teresa and Ray. I felt ashamed for my frustration with them. A dull ache grew in my chest as I thought about what Joe went through as he died.

  Our father wants everything to be done to keep him alive. You people couldn’t do your jobs in the clinic, so now he’s here and you better do your damn best to keep him alive because that’s what he wants.

  I hadn’t expected that he would get sicker so quickly. And I certainly didn’t anticipate that he would die hours after our conversation. I scrolled through Mr. Brown’s chart and found Teresa’s number listed as his emergency contact. Minutes passed as I stared at her number, wondering if I should call to see how she was doing, to tell her how sorry I was to hear of her father’s death. I started to punch in her number on my office phone, but stopped a few numbers in. What did I plan to say to her? Given our last interaction, wouldn’t my call only upset her? Was I calling for her or for myself? I hung up the phone.

  Maybe I was just jumping to conclusions and assuming that Teresa would have only harsh, unkind things to say, I thought. If I regularly called other patients’ families to offer my condolences, I should call her. I picked up the phone again and began to dial her number. I hung up after two rings.

  Eleven

  THE GRIP OF LIFE

  I wore freshly pressed gray pants and a pink top to Ms. Carson’s funeral service. “Please don’t wear black,” Gina told me when she’d called to invite me. “Mom specifically told me that she wanted lots of color, none of the usual funeral dreariness.”

  “I feel like your mom would want me to bring a date,” I joked with Gina, who laughed.

  “She never stopped talking about that,” Gina said. “She was hell-bent on meeting the boyfriend you told her about.” I hadn’t had to tell Ms. Carson much. She somehow knew that I’d started seeing someone. “You’re in love, aren’t you?” she exclaimed one day as I knelt down to determine the exact amount of dark fluid that drained from her abdomen into the plastic container at her bedside.

  “Mom, stop!” Gina exclaimed, rolling her eyes.

  “So let’s talk about your belly,” I said to Ms. Carson, winking. “Gina told me you were in a lot of pain over the last week.” As I pressed my hands around her abdomen, she let out a long, loud fart.

  “Good Lord, I am so sorry, Doctor!” Ms. Carson exclaimed, turning bright pink. Gina bit her lip, shaking silently as she held in her laughter.

  “Don’t apologize! I’m just glad you’re passing gas. Means that your intestines are moving around. Do you feel a little bit better?” I asked, shocked that a woman with a near-complete blockage of her bowel had managed to fart.

  “How can you stand it, doing this sort of work when you are so young and have your whole life ahead of you?” she asked, sidestepping my question. “Why are you here with this farting old lady?” Back in fellowship, I realized I’d committed to an interesting symmetry, building my own life as I cared for people confronting their mortality. I’d made the choice to practice this field of medicine, but I’d also been drawn toward it, maybe ever since the time my father taught me that impermanence defined every life and being, from myself to my parents to the clouds in the sky above us all.

  “I think it’s just what I was meant for, just like you were meant for teaching,” I said, smiling. “I can’t really explain it.”

  I sat toward the back of the church in a pew lined with copies of the program, which was filled with photographs from every stage of Ms. Carson’s life. A photograph from her wedding, when she’d clutched a bouquet of white flowers tightly and stood next to her beaming husband. Gina in a red and black robe, flanked by her parents and brother at her college graduation. Ms. Carson as a new mother, gazing at her sleeping newborn swaddled in a blanket. I read her biography and realized how much about her I hadn’t known: that half of her family was from South America, that she’d been both a teacher and a swimming coach.

  The service began, and I took in the remarks by Ms. Carson’s family, her colleagues at the school where she’d taught, a former student. I wiped my eyes with my bare hands until a kind usher brought me soft tissues. I cried not because I was sad, but rather because I was moved by the words spoken, the tone in which they were delivered. If death is the dropping of a stone into a still lake, perhaps the ripples toward the shore are the imprints we leave behind, the change that we effected simply because we existed. We may disappear into the water, but our significance doesn’t drown.

  “Say ‘death’ and the whole room freezes,” writes the poet Jane Hirshfield.

  even the couches stop moving,

  even the lamps.

  Like a squirrel suddenly aware it is being looked at.

  Say the word continuously,

  and things begin to go forward.

  Your life takes on

  the jerky texture of an old film strip.

  I’d used the word “death” more in the past two ye
ars than most people probably did in a lifetime. I’d watched my patients look death in the face almost every day, until it had become as ordinary as the photographs that filled Ms. Carson’s funeral program, just as natural as the sunrise and sunset, words Gina used in her speech to describe her mother’s birth and death. Death still moved me, still struck me as profoundly sacred, a force I regarded with great respect. It could still frighten and overwhelm me, though it did so less frequently. Because I’d also seen that death wasn’t mighty enough to strip away the meaning and lasting impact of a human life. Death was even an unexpected reminder of human equality, demonstrating that no matter how different we might be, we were unified in the brevity and fragility of our lives. Death didn’t have the power to undo a life and its legacy. But perhaps the fact of death amplified life’s significance.

  “The grip of life,” Hirshfield reminded me in the closing lines of her poem, “is as strong as the grip of death.”

  * * *

  A few weeks later, my colleague from USC called to tell me that she’d been able to secure funding for a second position on the palliative care team, and she wondered if I could come in for an interview the following week. The day after I interviewed, I received a call from the division chief of internal medicine offering me the job. For weeks, I wrestled with what it would mean to leave the same hospital system where my mother worked for thirty years, to leave a job after just one year. But when I imagined what awaited me—being a part of a young and growing palliative care team, teaching and mentoring medical students and residents and fellows, maybe even having some time to write—my exhaustion gave way to excitement.

  Days later, I said yes.

  * * *