One of the daughters, who tended to be feisty at times, reminded the attending of this sharply. “We already discussed this yesterday. We don’t need to go over it again.”
“I realize that,” the attending said, “and I don’t want to cause you any further pain, but I think it is worth discussing again. I just reviewed Mr. Spratt’s case extensively, and I have to tell you that I think he is declining quickly. His kidneys and liver are failing, and it is only a matter of time now. If you choose to keep him at full code, he will be resuscitated when he dies. And what you need to realize is that this will not prolong his life significantly.”
What ensued was a calm and honest discussion, and the family decided not to resuscitate him but instead asked that he receive comfort measures only. Those ten minutes of discussion radically transformed our treatment plan; the goal was no longer to try to improve his condition, but rather to stabilize him so that he could go home to die. More important, it telescoped the situation for the family. Not only was he going to die, but soon. It seemed to me, although I could not know for sure, that no one had given them this message before or laid it out so clearly.
It is a very strange experience to be present at the most significant moments of others’ lives, when you have no prior intimate connection to them. It is equally disconcerting to be in the midst of one of these life-changing points in time and to realize that the world is proceeding as usual around you. There is a wonderful W. H. Auden poem, “Musée des Beaux Arts,” that describes the incongruity and loneliness of suffering in isolation while others are engrossed in their everyday activities, as in my favorite line, while “the dogs go on with their doggy life.” I was acutely aware of this uneasy coexistence of the profound, the tragedy occurring in their lives, and the mundane, what was going on in the hospital around them, during that conversation, and again, when Mr. Spratt died two days later. It was a Sunday afternoon, and I had been writing a summary of his case, an “off-service note” for Mr. Spratt’s intern, who was leaving the following day. She and I had also spent a good deal of time discussing how to present him to the new intern and resident and how to manage his discharge home. Earlier that day, the family had asked her if he could go home that evening. The intern hesitated about it and said she was not sure he was stable enough. I beseeched her, but my motivation was not entirely selfless. I wanted him to go home quickly so he could die surrounded by his family, but to be honest, I was also scared to be the only person left on the team who knew anything about him, especially when he was at death’s door. We made some calls to see about getting him the proper hospice care at home that night, but it turned out to be impossible. Frustrated, I went to check on him, only to find that all his family was in the room. Not wanting to intrude, I ducked across the hall to see my new patient. And during that fifteen-minute interval, Mr. Spratt departed this world.
I walked out of my new patient’s room to see the intern emerge from Mr. Spratt’s room. I asked what was going on, if I could do anything.
“You know he died, don’t you?” she said abruptly.
I did not. I grabbed her arm and repeated incredulously, “He died? Oh my God, oh my God.”
I do not know why in that moment I had such trouble accepting it as fact. She kept walking toward the end of the hall, where the family was clustered. I followed, but she motioned me to stay back. I felt frustrated, and conflicted. I had a strong urge to go with her, to offer what little consolation I could, although at the same time I was scared to go.
As I waited for her, I thought back to the time when my grandfather died of a hemorrhagic stroke at Duke Hospital. I recalled the nurse who brought us drinks when we were saying good-bye to him; people still get thirsty at a deathbed. I remembered the kind person who gave us her cellular phone—for some reason, we could not use the emergency-room phone to dial long distance—so that my grandfather could say his final words to his son. I recalled the young neurology resident who told us, so kindly and so regretfully, the news that he was going to die imminently. All of these people and these moments mattered. Although these people did not fully share our grief, their acknowledgment of it, their witnessing it, and their concern for us, the survivors, was truly meaningful. I wanted to honor the grief of the Spratt family. I lingered in the hall until his wife and two daughters came out of their talk with the intern, and I stammered that I was sorry for their loss, that I had enjoyed knowing him, and that he was a wonderful man. They nodded tearfully and made their way to his room.
As I rode home that afternoon, the sun was shining brightly, glinting off Jamaica Pond. How precious, brief, and transient is life. My feelings about Mr. Spratt’s death were a mixture of sadness and relief. I thought back to that morning when he had a moment of lucidity, roused from his alternate reality long enough to tell the attending that he wanted his restraints removed. “Now, n-o-w, now, doctor, and I mean it. I want to be free.” Released from the shackles of his body, he finally was.
Imagine How You’d Feel
Andrea Dalve-Endres
THE EMERGENCY ROOM was overflowing upon our arrival that afternoon, unusually so. Patients were spilling into the hallways, sitting in the halls, filling the waiting room. My student partner and I were sent off regularly to see patients and come back with our evaluation. Upon return to the front desk, we found a distraught nurse who told us to go to the code room; she simply couldn’t because she had a six-month-old child herself. It didn’t sound good.
In the code room … it was coordinated chaos. The attending physician was calling orders, people were running around the room locating supplies, monitors were being gathered, information was being rattled off to the nurse, and in the midst of it all, on the gurney was this precious little baby. As I watched the action from afar, it seemed surreal. The father wailed and flailed his arms, looking very disheveled and smelling of alcohol. The baby’s mother arrived and also went into hysterics. Who could blame them?
The medical team continued trying to revive the baby for what seemed to be an incredibly long time—fifteen minutes since we’d arrived in the code room and the heart monitor hadn’t bleeped once—until finally the child’s death was announced. In fact, the child was likely dead upon arrival at the hospital, but nonetheless, they had to try.
The father became aggressive, punching the emergency-room door, and security was called. Fortunately the situation did not escalate. However, the mother wanted to sit with her child for a while to say good-bye. The attending physician said he would find a nice, quiet room so that she could stay with her child for the time being. Then she asked if it would be possible for her to take a photo with her baby one last time. Hoping that she’d change her mind, he suggested instead that she just spend time with him quietly and said they could talk about the second request a bit later.
How long, I wondered, do you really try to resuscitate, or is there a point when you know it’s futile and yet you continue to try? Or maybe you don’t want it to appear to the parents that you are giving up? Do you always permit the parents into the room when their child is in a code? And I thought, Sitting with a child who has recently died is one thing, but wanting to take photos together really seemed morbid and probably unhealthy, at least in my mind. But maybe it would offer a sense of closure.
The mother stayed with her child until the evening and was still there when I left. What would happen if she didn’t want to leave? I wondered. And how long was too long? Her child had just died, and I found myself asking, How easy would it be to just walk away?
When the attending had mentioned that the mother wanted a picture with her child, my stomach had turned; something about that didn’t sit well. The attending had not yet decided what he would do, and I never actually found out the final outcome of this dilemma. I hoped that the mother would decide it wasn’t such a good idea, or that once she calmed down, they could dissuade her, encouraging her instead to remember her child in life and not in death.
Squeeze Hard
Brook Hill
“MR. TREMONT, SQUEEZE my hand,” I shouted. And he did.
I live and work in a world of confusion. Although Mr. Tremont’s exhausted squeeze surprised both me and the nurse, her discomfort seems to further increase as I continued to hold his hand in silence, dumbfounded and unable to move. Although Mr. Tremont’s body was broken beyond the point of repair, his spirit remained.
Aside from him, we all knew what was about to happen. The barbaric trifles of modern medicine had failed, and now we were forced yet again to yield to, although never to face, our own limitations. Now was the time to let Mr. Tremont fly. He would never breathe on his own again. The family had spoken their last words and left. We had done all we could, so we said, and now it was my responsibility to execute the plan.
I can’t say that I have ever so uncomfortably written an order or intervened on a patient. Only minutes earlier, I had unintentionally discomfited several coresidents by calmly yet proudly placing a femoral line in a pulseless patient, a task we all knew they could not achieve. I had done my Harvard teaching-hospital scrubs well. My surgery course director would be proud. Or would he?
I scribbled the orders in apathy, the cool dispassion that reigns daily between the hours of 3:00 and 5:00 a.m., and headed off to sleep. But for some reason, I felt an exhausted urge to revisit his room once more before leaving. Take him back to the light, I thought to myself with eyes closed. Take him by your side, take him in peace. I looked around to make sure no one had been watching, and left. The life within Mr. Tremont was weak, but the life within me was weaker.
It wasn’t much later that I was back in the unit, rounding on the patient in the adjacent bay.
“Does anybody want to call the family? He’s on his last breath,” I heard from next door.
“Someone should at least hold his hand so he doesn’t go alone,” volunteered one of the nurses with sarcastic unease. “Especially since the family isn’t here,” added another.
But we didn’t. We hadn’t the courage. Instead we stood as spectators, separated from the action as if by a thick glass, discussing his junctional rhythm and his loss of blood pressure when the silence grew too long.
“Easy note this morning,” I kidded to the pulmonologist.
Now I sit at home in silence, still fatigued, wondering what went wrong this morning. When did society decide to play the coward when confronted by our own image? Why are we all somehow ashamed of what we each know is right? Why can’t I hold the hand of a dying patient when it brings not even a flinch to hold his heart?
I am sorry, Mr. Tremont. I have failed you twice. Despite the best efforts of my family, my friends, my teachers, and myself to create a man of virtue, I remain weak. In a hospital founded by people who reached halfway around the world to reassure lepers that they hadn’t been forgotten, I failed to reach halfway across the room to do the same for you. I don’t know if you still exist, or if I will ever see you again, but if you do, and if we should meet a second time, I will surely beseech you the next time I take your hand, Squeeze hard, my brother. Squeeze hard.
Code
Joan S. Hu
I AM DISCUSSING MY MOST recent admission note with our senior attending physician in his office late on a Friday afternoon when he receives a page. He squints at his pager, then turns to look at me: “Guess what, your patient is coding—right now.”
My patient, my patient whose differential diagnosis we have just been discussing. My patient whose family had expressly stated to our team that he was to be “do not intubate/do not resuscitate” in the case of cardiopulmonary arrest. My patient, whose family has suddenly changed their minds.
My mysterious seventy-three-year-old gaunt and frail Jordanian man who says, “Hello, Doctor, How are you?” and “Thank you so much, Doctor,” every time I arrive and leave his hospital room, though I am so much less than a doctor (and I think he knows that). Mysterious because he came into the hospital with pneumonia-like symptoms, weight loss, and difficulty breathing from emphysema. Mysterious because his left lung has a huge collection of loculated fluid, and the radiologist and our attending have gone back and forth about whether the fluid is infected or malignant. Does he have pneumonia, or does he have cancer? Drainage of the fluid yielded indefinite results. We had considered obtaining biopsies of the lung itself.
Except that this morning, during rounds, we found that his oxygen saturation had dipped into the low eighties overnight. And his dark skin, draped over his tendons and bones, looked a poor trap for the meager life within. I was so surprised, indeed very surprised, when our attending said privately to our junior resident and me, “You know, it is very likely cancer. I would not be surprised if he doesn’t last through the night.” And the look in his eyes was knowing, mingled with pain and pity.
How did he know? How was he so right? And how was I to know, here nearing the end of the first month of my medicine rotation? I had no inkling of how prescient those words were until I walk into his hospital room, my patient’s hospital room at the very end of a long corridor, in which are packed some twenty people, the code team, my junior resident, other residents and the senior medicine resident, our attending, and what seems to be every nurse on the floor.
It turns out that my patient became breathless and pulseless moments before, and his family in their understandable frenzy and disbelief reversed his code status and changed him to full code—use all necessary measures to regain life. His body now lies on the bed lifeless, and around him lanterns of IV fluids, monitors, and pressor bags are being raised. At least four people stand on each side of him, with one at the head, and the senior resident, running the code, at the foot of the bed. He yells, “Will someone confirm femoral and carotid pulses!” “How much epi has gone in so far?” and so on, while my patient’s two sons, grown men, stand near the head of his bed, their eyes red with weeping, looking on at the production in utter bewilderment.
My patient’s wife, whom I have met only once, is sitting in the corner of the room, her head wrapped in traditional Muslim head scarf; she stares vacantly at her husband’s body on the bed, his body intermittently shocked into motion by the electric paddles, and then she looks down, stares at her hands, rubs them down her knees, and weeps inconsolably.
The tiny hospital room has probably never had so many breathing souls in it at one time until now. I find a chair next to my patient’s wife, place my hand on hers, and squeeze her hand and tell her that everything is going to be OK. I think that it is permitted, even in the strictest Muslim traditions, for women to touch other women’s hands, and I find that this is the least, and the most, that I can do. I ask her if there is anything she needs, and I find her a box of tissues. And besides that, what else? As we witness the pandemonium of resurrecting the dead.
It turns out that they’ve succeeded. They are able to obtain a weak pulse and a measurable blood pressure after two rounds of cardioversion and intravenous pressor agents. The code team decides that our patient must be taken to the medicine ICU, where he will receive the best in intensive care to maintain the meek pulse and prevent it from sputtering into oblivion.
Our team, the attending, the junior resident, and I, take the family into the waiting area next to the ICU, and behind a closed door, we discuss the issue of the code status. My teachers, with consummate delicacy and rapport, with all the sympathy and understanding they feel and can muster, ask the family, “Why did you want to reverse the code? What changed?”
Their reply is interesting and takes us completely by surprise: “In our religion,” says one of the patient’s sons, “we believe that every creature has a time to live and a time to die, and every last breath he breathes is given to him by God. And what we believe is that you are God’s angels; you do God’s work. God has given you the power to bring life back to my father’s body; God allowed you to create and invent these modern medical machines so that you can hork His miracles! Our Allah is the same as your God, and you must understand that, for us, we cannot give up on our fa
ther until every last resource is exhausted, until we know that God means for him to live or to die.”
We are dumbfounded. Here we are, confronted with a modern paradox. During this entire discussion, my attending and our junior resident emphasize, very gently, to the family that this is not how most people would want their loved one to die. That their father will die a slow and agonizing death attached to these machines in the ICU, instead of dying a quiet death at home, as the family originally wished. They explain that he has in fact already died and the electrical pads and medicines have literally grasped him back from the jaws of death, but that he will die soon, no matter what we do, and that what course his death takes, what peace and serenity we can give him, away from the whirring and dinging of monitors and the bleakness of the ICU, is up to them.
But they will not change their minds: they are determined to give their father the last chance at life, however brief that may be. They are hoping for a miracle, and they tell us as much. Except that, except that—we are supposed to be the miracle workers. God’s angels.
And as our futile disagreement continues, the ICU resident knocks gently on the door and touches the arm of our patient’s wife. “I am very sorry, but your husband has just passed away.”
And therein the discussion ends, and we are ushered into our patient’s ICU room for the family to say their good-byes to him, and for us to say good-bye to him, our mystery patient whose killer we shall never know. The family refuses an autopsy. Apparently 600 cc of pericardial fluid had been extracted from around his heart in the ICU before he finally died and resisted all attempts at resuscitation, but that fluid was discarded in the midst of the chaos—so now we really shall never know.
The Soul of a Doctor Page 11
