by Tilda Shalof
“My mother and my aunt Theresa don’t want any more meetings,” she said.
“Not a big meeting, a little one, here in the room. Not in the quiet room. Not sitting down, standing up. A short talk, here in the room.”
The daughters had been eluding us. They had stopped answering the phone or returning our messages. One day they sent a fax with a series of requests, including one that their father was to be treated only by senior staff physicians, no residents or interns. The room was to be kept at precisely 22°C. There were to be no cool drafts or glaring lights. They requested that only “the cheerful nurses” be assigned to their father’s care. “We do not want people with negative thoughts caring for our father.”
On the day when Mr. Bellissimo’s heart rate slowed to a sluggish 50 beats a minute and the few drops of urine that he put out were black and full of sludge, Dr. Leung was the attending staff physician and I was the nurse in charge.
After all these years, three children, numerous scientific research studies, and hundreds of academic papers, Jessica showed no signs of aging. She was still so beautiful.
“I guess we’ll have to offer them dialysis,” she said firmly, but I saw by her averted eyes that she was not exactly at one with this additional intervention herself.
“But Jessica,” I said, “what will we gain by offering dialysis?”
“The daughters are representing his wishes. These are his wishes.” She shrugged her shoulders as she added, “Apparently.”
“But they’re not acting in his best interests! They’re not rational.”
“I have spoken with them at length, and I’m convinced they believe this is what their father would have wanted. It would be presumptuous and arrogant of us to move to a paternalistic approach and assume we know what is best for patients. Not only that, but in this case it could become highly adversarial.” She sighed wearily. “Tilda, think about the situation it puts us in if we override them. You have to understand where we, the doctors, are coming from.”
She saw my skeptical expression. I could feel it on my face.
“I don’t know!” She held up her hands. “We don’t have all the answers.”
“No, but neither do the daughters and they’re making bad choices,” I said. “How can we protect the father from his daughters’ bad choices?”
“Tilda, you presume that you know what’s best for him, even better than his own family?”
“Jessica, this poor man is rotting in the bed. I’m merely stating the obvious! It’s common sense!”
“How can you know for sure that Mr. Bellissimo wouldn’t want this done?”
“Do you know anyone who would?”
Jessica took a deep breath and composed herself.
“The thing I value the most, the thing that is most important to me in my practice is to be completely transparent and honest in everything that I do. Constitutionally, I am not able to tell a lie. That is who I am, and the day that changes is the day I get out of this profession. It is our duty to carry out the patient’s wishes. Therefore, I have no qualms about this situation. I’m here, along with the nurses, to support the decisions the family has made. Let me remind you, Tilda, that we are not here to pass judgment. This is our job, whether I agree with the family or not. It is not about our beliefs, it is about the patient’s beliefs.”
Then it was my turn, and Jessica listened to me with equal patience and respect.
“To me, Jessica, the thing I value most, the thing that is most important to me in my practice is kindness. Nothing is more important to me than doing work that is kind. That’s why I’m having such a difficult time with this case. It is cruel.”
“This is not an assault and battery. Let’s remember that,” she said, bristling slightly at my intimation that she would be a part of anything that was cruel. “We are all motivated here by a desire to do good. Please keep that in mind, Tilda.”
“Yes, but what we’re doing isn’t benevolent. Anyone can see that …” I was losing steam.
“How would you handle it then?” she asked. “Pretend it’s you now, Dr. Shalof.”
“I wouldn’t offer one more medical intervention, certainly not dialysis or CPR in the event of another cardiac arrest. I would immediately insist on withdrawal of treatment and turn the focus over to comfort of the patient and support of the family. I would bring in second, third, fourth opinions, for the professional corroboration. I would bring in legal advisors, if necessary. A judge. A court injunction. An appointed guardian.”
“All that could take weeks in itself,” she said, smiling at my simple-mindedness. “In the meanwhile, we’re not harming him.”
“Oh, yes, we are,” I said. “I guess it’s different for the nurses than for the doctors. We’re right there with patients, minute by minute, day and night. We do these things to the patients. We see them in the state they’re in. We see the family’s suffering and how we are prolonging it. The doctors come and go. Have you seen how Mr. Bellissimo’s skin is all dripping, open sores? Have you watched how he grimaces in pain with whatever we do to him?
We keep giving him little boosts of epinephrine to keep him going all day. We can’t even give him much morphine because it drops his pressure too much.”
“I hope you don’t feel, Tilda, that my word prevails over yours,” Jessica said.
I knew she was trying to be conciliatory and draw this unsettling conversation to a peaceful close. She didn’t need to do that. She and I had become friends as well as colleagues, and I had grown to love and respect her. We had worked together for years. I remembered when she started out as a resident, then as a senior fellow, and I was such a neophyte nurse, just trying to keep up with the basics. Our argument was not personal or acrimonious, even though it was vociferous and emotional.
“We are a team,” she insisted.
“Yeah, but why do the daughters prevail?” I could hear myself whining like a child.
“They’re the next of kin. You know the law, Tilda. I am simply following the law.”
“The law cares nothing about compassion or the dignity of real people! We’re making him into a freak, and allowing him to become grotesque. What we are doing has no purpose other than to mollify the daughters, to avoid confrontation, possibly even litigation –”
Laura came over to us, carrying something in her hand.
“How did you know there could be a lawsuit, Tilda? One of the daughters just sent this fax. It says her father deteriorated while under your care yesterday, and she thinks you caused it. She’s threatening to bring in a lawyer to review the chart. She’s got it in for you, baby!”
“That’s fine. I have nothing to hide.”
“Are you on a mutiny?” Laura looked amused. “You know you’re becoming a drama queen.”
“No,” I answered, “I’m refusing to take care of this patient. I am a conscientious objector, a peace activist, and a front-line soldier. I’m going on a work-to-rule campaign.”
That was that. For now.
“IF YOU GUYS are going to talk about Mr. B., I’m leaving,” Laura said after work that evening. We were in a bar near the hospital, having drinks. “I don’t want to hear another word about that case.”
“No. There’s nothing to talk about. I simply refuse to take care of him,” I said.
“Are you on strike?”
“Kind of.” I knew I wouldn’t last.
“You won’t last,” Laura said.
“There’s no way I’m going in there again either,” said Tracy. “I’m with you, Tilda.”
“Every human being deserves nursing care,” said Frances. “I don’t like it either, but I’ll take care of him. I agree with Jessica Leung. It’s our duty to carry out people’s wishes. As nurses, we can’t just give up on a person because we have a disagreement with the family. We have to put our personal opinions aside and do what is right for the patient.”
I decided to boldly take the lead with an idea I had been cooking up, privately. I was ready to
spring it on them. “Listen guys,” I said. “I’ve figured out what we have to do to make sure this never happens to any of us.”
“I thought we said we weren’t going to talk about work!” protested Laura.
“I’ve been thinking of getting a tattoo on my chest that says ‘Do Not Resuscitate,’” said Nicole. “After this case of Mr. B.’s, I’m not taking any chances. When the time comes, who knows what my family will do with me? Oh yeah, and one more request, make sure Murry takes care of me. I know he’ll pluck my chin hairs and touch up my grey roots before my family comes to visit.”
We all knew she took her mortality more seriously than her light-hearted words indicated. For some time we’d all known that Nicole had been preparing photo albums and storing away treasured keepsakes for the children whose names she’d already picked out and whom she hoped to have one day. Frances sipped her beer quietly. After all, it wasn’t the first time we’d had one of these apocalyptic conversations.
“Dump my carcass in a garbage can,” Morty said. “I don’t believe in graves or funerals and I certainly don’t want my liver going to some drugged-out alcoholic.”
“We have to draw up living wills, decide on our advance directives, and write everything down,” said Tracy. “We have to make our wishes known. Sign our donor cards. What else is there to do?”
“I’ll tell you what I’m proposing,” I said. “A pact. We’ll appoint each other – our group – to be the decision makers for one another if any of us gets critically ill. We’ll communicate clearly to one another what we want done in various scenarios – make our wishes known – as well as putting it in writing. We can’t leave these decisions to our family. They won’t know what to do. Who would know better what to do than us? Who’s in on this with me?”
“What about the last remaining one?” asked Morty, thinking this over.
“I don’t know, I guess she’ll be on her own. I haven’t worked out all the details, yet.”
We fell silent. We’d had enough talk of death. But it was something worth considering, they conceded. Perhaps some other time, on another day. On another occasion. Not now.
18
SHIFT CHANGE
The ersatz Chinese buffet offered everything imaginable, from pad Thai to cole slaw to egg rolls to lasagna – fortune cookies and apple pie, too – and we stuffed ourselves, drank silly cocktails, and stayed, talking until the restaurant cleared out. Then Frances brought out a cake for Nicole’s birthday and for once it was made of the proper ingredients – butter, sugar, flour, eggs – she didn’t cut any corners. We were celebrating so many things that night, but most of all, our abiding friendship, bonded in the work we had been doing together for almost fifteen years.
That night we were in mourning, too. Just a few days ago we had heard the shocking news that Nell Mason had been found dead, the cause unknown. Frances, and others, had tried to stay in contact with her over the years, but she had drifted farther and farther away from everyone and now, this.
“It’s tragic,” said Frances. “What a fabulous nurse Nell was. Daniel Huizinga used to say, if Nell says there is something wrong with the patient and if he couldn’t find it, he’d stay all night if necessary, until he figured out what was wrong. He trusted her completely.”
“We all did,” said Laura, who was choked up. “Maybe I shouldn’t have made such fun of her. But all those crazy excuses and – let’s face it – far-fetched stories! Some of them were pretty amusing, though,” she said with a chuckle.
“Could any of them have been true? The pet camel? The elevator cutting loose? The wild dogs on the beach and how she poked” – I made the motion with two fingers jabbing the air – “and then pulled” – I yanked down the imaginary head of the dog under the pretend ocean surface – “them and drowned them to save her life?”
“Did she ever tell you about when she ran a medical station on a native reserve all by herself?” asked Laura, who couldn’t resist just one more. “One day a man and a woman were brought in, stuck together. Yes, after sex, they couldn’t separate themselves. ‘So, how do you treat something like that, Nell?’ I asked her. I thought, finally, I’ll catch her. Without missing a beat, Nell said, ‘Chlorpromazine, 50 mg IV, does the trick.’”
“To the man or to the woman?” I wondered aloud, but no one answered.
“There was always an element of truth in those stories,” said Frances. “Nell was such a wonderful nurse and such fun to work with. I learned so much from her. I imagine that if an alien from another planet came to Earth and said, bring me your best nurse, everyone would agree that it would have to have been Nell.”
“I’ll miss her,” I said and then added guiltily, “and her stories, too.”
IN THE WARM glow of a candle in the middle of the table, I looked at the faces of these women and felt a sweet wistfulness. I wanted us to go on working together forever, but I could sense restlessness in each of them and we all had known for some time that changes were in the works.
It was time for cake. Nicole was just about to raise the knife, but for some reason hesitated and passed it along to Tracy, who also couldn’t make the first cut. Tracy moved it over to stop in front of Morty, who had recently gone back to calling herself Justine. She said she’d had enough of the old prank. Even her earrings had changed: she was wearing simple gold studs.
“Sure, I’ll cut it,” she said.
Justine grasped the knife, steadied the blade with her index finger, and pulled it down smoothly, first through the air, then through the frilly pink roses and the white blanket of icing, down as neatly and cleanly as a golf swing, the skill she’d just learned under Nicole’s tutelage. Justine was looking forward to playing with her new husband (she had divorced the first one, Tom) who was an avid golfer. They had met co-starring in lead roles in a local amateur production of Grease.
Justine passed the cake to Frances, for whom cake cutting was not as straightforward a procedure. Her hand wavered. She was on Weight Watchers once again and had been good all week, in order to allow for this treat. She widened, then narrowed the angle for her intended portion, and then changed her tack altogether.
“How about I cut you a slice, Nicky, seeing as how you’re the birthday girl?” Nicole, newly pregnant and a bit queasy, still could be accorded a generous slice. Frances brought down the little caloric guillotine.
For her own slice, Frances dragged the knife down slowly, like a senior citizen doing the crawl in a Miami pool. She took her time and did it as if against resistance, as if she’d cut many, many cakes in her day and knew all too well the complications and implications involved in cake cutting.
“Pass that cake down here,” growled Laura. “What’s taking you guys so long?”
In Laura’s hand, the knife came down swiftly, causing the roses to spring back in surprise. We looked at one another and smiled. Laura slapped a hunk of cake and icing to her plate, sat back in her chair, and brought the plate and fork to her mouth as if she were ravenous. No, it wasn’t possible – we had just finished a huge meal – but she craved the sweetness.
“You need to get laid, Laura,” said Justine, across the table from her. “You’re horny and you need a good –”
“Good, bad, or indifferent, I’ll be eating cake until that happens.”
“Maybe what you need, Laura,” I suggested, “is a break from the ICU. Why don’t you take some time off and go on a long vacation somewhere?”
“I am going somewhere,” she announced, taking us by surprise.
“So where are you off to, Laura?” Nicole asked.
“Medical school,” she said calmly.
“No!” I said in alarm.
“Yes.”
“No!”
She smiled.
“What a sellout!” I said.
“‘You’re too smart to be a nurse, Laura, why aren’t you a doctor?’” Laura said in a mocking voice. “People are always telling me that I’m wasting my talent as a nurse. I tell them it takes a
lot of intelligence to be a nurse, but they don’t get it. I say to them, aren’t you glad there are smart nurses like me, caring for people? They still don’t get it. Well, I’ve had enough! I’m going to be a doctor. I’ll make decent money and maybe get some respect.”
“It’s very hard to get accepted to medical school,” I warned her. “You might not get in.”
“I’m in already,” she said. “I got my acceptance a few days ago. Nurses know to go where the need is and I told them I’m prepared to go to a remote, under-serviced area and I think that helped get me accepted.”
“Are you?”
“Of course.”
“What a loss!” I said.
Of course, I could see how a solitary, isolated medical practice would suit Laura well. She could be the surly, self-reliant maverick that she was and probably do a lot of good for people who really needed it. They would love her. She would make a wonderful doctor.
No one noticed Tracy taking a modest slice of cake. We still so often overlooked soft-spoken, unassuming Tracy, yet I had come to understand that she wasn’t withdrawn or remote, just quiet, thoughtful, and lately preoccupied with her father’s health. About a month ago she had called us at work, and the number on the telephone display was an internal hospital extension.
“Where are you?” I asked her.
“I’m downstairs in Emerg.”
She was always calm in any situation, but now I could hear her voice tremble.
“What happened? Your kids okay? Ron?”
“It’s my dad. He had a heart attack.”
“We’ll be right down.”
Pang-Mei took over my patient for me. “Of course, go down and see Tracy’s father. I know what it’s like. My mother had severe abdo pain the other night and I had to take her to Emerg. ‘No, no,’ she told everyone who came near her – she barely speaks English, she’s worse than me – ‘I a DNR. I a DNR.’ I told her, no, Ma, we’re not there yet, the doctor just wants to do an X-ray!”
“She’s lucky, Pang-Mei. She’s got you and you’ve prepared her well.”
