by DANIEL MUÑOZ
When his wife asks, “Is he awake at all?” I know she’s beginning to understand. I tell her, no, he probably won’t know that she’s in the room. Then she asks the inevitable—what happened and why. What did I do? He was fine two days ago. What should I have done? The bottom line is, we don’t really know. I tell her, “What we know, based on the testing in the last eighteen hours, is that he’s a man with serious medical problems, and people like that can get very sick, very quickly.” More important, I add, “Sometimes there aren’t clear warning signs. You didn’t miss something. It isn’t your fault.” Dealing with the likelihood of his death is enough; there’s no reason she should be blaming herself. Her friends listen and hold her hands. Though only in their fifties, they aren’t pictures of health themselves. Mrs. Werdna’s support team seems as weak as she is, gathered for a vigil over the one who’d, at least to them, seemed the strongest.
Dr. Martin, who has been quietly monitoring the scene, leans forward now and looks at Mrs. Werdna. “Sweetheart, how are you holding up?” Her face says, “As well as I can.” He goes on: “I have to tell you, we doctors are not miracle workers. There are some questions we don’t know the answers to.” With these plain phrases, he resets her expectation levels to reality. We don’t have all the answers. Sometimes there are no answers. He then reiterates the medical plan. “As Dr. Muñoz said, at this point we’re most concerned with his brain because he went too long a time without oxygen to the brain.” The choice of words, “too long,” was again simple but strong, perfect communication, so subtle an outsider might miss it. The last thing we want to do is provide false hope, nor should we label a tragedy prematurely.
I’m taking mental notes on every nuance. This is not something med school, residencies, or fellowships necessarily teach. Our time is filled cramming knowledge and experience into us, and little is left for human subtleties. We’re supposed to pick them up on our own, which means that some people never do. I’ve seen academically brilliant colleagues who talk to patients and families as if they were spouting data into a digital recorder. “This is stage IV melanoma. There are treatments but no cure. Expected survival is from four to thirteen months….” Arguably, it cannot be taught. Either you’re someone who is sensitive to people or you aren’t. That’s why when you come across a Dr. Martin, you know you should pay attention. We’re here to treat people, not charts.
Mrs. Werdna asks Dr. Martin if her husband is in pain. He leans in, speaks softly, slowly, and compassionately, and puts his hand on hers. “I can tell you, he is not. Your pain is far greater than the pain he feels. I know you hurt right now.” Her husband is not suffering. Because his brain is not working properly, it will not allow him to sense pain. Dr. Martin conveyed all that without relying on cold medical words. I am blown away. I’ve never heard another doctor communicate this way.
Mrs. Werdna looks at Dr. Martin and gets teary but doesn’t break down: She is physically frail, but rock solid in character. Then she says something that I’ve heard before, but that always amazes me. She thanks us. We’ve just told her that her husband is hanging on to life by a kite string, and that his brain has likely already let go. But she says, “Thank you all for everything you’re doing for him. He couldn’t be in better hands.” Families invest their confidence in our medical knowledge, but evaluate us on our ability to connect. If you can connect, you’re a good doctor. If you can’t, you aren’t. It isn’t rational, but it’s not crazy either. Oftentimes, patients and family members can gauge only the human elements. Do you hear me? Can you feel my distress? Do you care? Mrs. Werdna says she and her husband couldn’t be in better hands, an opinion that is largely based on Dr. Martin’s communication skills, not actual proof of his clinical ability. In theory, we could all be mediocre. But that’s what a lot of good medicine is about—reaching the patient or family so you can practice good medicine. If the adage “Ninety-five percent of success is showing up” is true, the medical corollary is, “Ninety-five percent of being a good doctor is the ability to look the patient in the eye.” I am not ashamed to say I will try to memorize what Dr. Martin said, how he said it, his pauses, even his facial expressions. He is a master at this, and this is one of the most indelible lessons of my career.
After the meeting, we guide Mrs. Werdna and her friends to her husband’s room. Dr. Martin backs out: “I want to give you time to yourselves. We’re just down the hall outside if you need anything.” She sits by her husband, but in reality, she’s alone. He’s not there anymore. I stay a few more minutes, then leave. An hour later, I see the neighbors escort her out.
At the next meeting about Mr. Werdna, I set the plan. We’ll wait a day on the remote chance things might improve, but our next meeting with Mrs. Werdna will almost inevitably involve telling her that her husband isn’t going to make it. Dr. Martin says only, “Sadly, I agree,” which surprises me a bit. From someone as understated as he is, that brief comment is a vote of confidence.
In the ensuing hours, Mr. Werdna’s organ systems improve but his brain does not. He’s just not waking up, although he occasionally exhibits jerking, seizure-like movements, episodes that are understandably troubling and confusing to his family. We speak to the neurologists involved to help manage these sporadic movements, but they are most likely the result of faulty electrical firings in his injured brain. It’s now Thursday, two and a half days after Mr. Werdna was admitted. He displays no primitive reflexes, but he is not technically “brain-dead.” His brain waves have not flatlined. His jerking motions show up as little blips on his EEG (electroencephalogram). But his chances for recovery are as close to zero as you can get. All of this brings up another major medical dilemma: At what point does keeping a patient alive because there is a very small chance then cross over into keeping the patient alive when there is no hope? There isn’t a specific moment in time—say, day two at 11:15 in the morning—when a patient’s fate is sealed. There’s no test that says, as of right now the brain will never recover. The judgment isn’t black-and-white; it evolves from gray.
I call Mrs. Werdna and tell her that it would be good for us to meet tomorrow: It is time for us to deliver our verdict. We could keep her husband alive attached to life support, but there is virtually nothing we can do to change his neurologic fate or make him better. Some families ask, “Does this mean he’d be hooked up forever?” We say, “Yes.” And they often say, “He wouldn’t want that.” This leads to a discussion of withdrawal of care (i.e., ventilator). And because some people die not in seconds or minutes, but in hours or days following that step, I want the family to fully understand the situation. I also ask Dr. Young, a second-year resident from Hopkins who is on-call that night, to attend the meetings as well. I want the family and friends to recognize her as a familiar face. If Mr. Werdna should die on her watch, in the middle of the night, that 1:00 a.m. phone call shouldn’t come from a total stranger.
Unlike our last meeting, this one has no rehearsal. We arrange ourselves around Mrs. Werdna, with Dr. Martin and the nurse sitting opposite her and her neighbors. Dr. Young sits at one end of the table, and I sit at the other. I summarize our earlier talk and then say, “Now, I’ve got to tell you that we don’t have good news.” I pause, just as Dr. Martin did, to let this sink in. Whenever he says something highly consequential, he stops to allow people to digest and process it. He knows that nothing we say in the next ten seconds will be heard, not after that. I wait, then go on. “Despite everything we have done to support and comfort your husband, to take the best care of him we know how, whatever brought this on has caused a severe injury to his brain.” That’s a lot to absorb—despite support, comfort, care, injury to his brain. Again, I wait for Mrs. Werdna’s recognition and continue. “With the help of our neurology doctors—the brain specialists—and with our own experience, we can tell you that his brain is not going to get better…ever.” Mrs. Werdna is teary but does not break down. I try to channel Dr. Martin by holding Mrs. Werdna’s hand as I go on. “One thing I can assur
e you is you are all in far greater pain than anything Mr. Werdna is experiencing right now. He is not in pain. He’s not suffering.” Dr. Martin is there, and although I have appropriated his speech almost verbatim, he is fine with it. The unspoken message is: This is what I teach. It works. Take it; use it.
Through her tears, Mrs. Werdna says, “I want you all to know how much I appreciate everything you’ve done.” She pauses, then says, “I understand he’s not going to get better.” Her neighbors nod. She asks, “What am I supposed to do?” She literally does not know what to do. Who does? Who has had experience with such things? Neither she nor I have ever been in this circumstance before. Despite my calm demeanor, I’m still struggling to respond when Dr. Martin says, “I agree with everything Dr. Muñoz has said. We are heartbroken and terribly sorry that you are dealing with this, that your husband has gotten sick in a way that he’s not going to get better…that he’s never going to wake up.” That last phrase, “never going to wake up,” gives finality to the scene. It’s no longer when or maybe or probably; it’s “never.” And “wake up” is the perfect, most empathic way to express this because it evokes sleeping rather than death. It is an easier image to deal with. “As Dr. Muñoz said, he isn’t suffering, doesn’t feel pain. The part of him that made him who he was, that was your husband for all those years, that man is gone. That part of him is in a better place now.” I know that I don’t have enough lines in my face to pull off the phrase “in a better place now.” But Dr. Martin has invoked it to imply that Mrs. Werdna’s husband has moved on, and now she can too. His words also free her from guilt, in case she’s not in the room at the moment he dies. Even though his heart is beating, he’s already gone. Dr. Martin has broken terrible news to Mrs. Werdna, given her permission to let go of her husband, and to do so without guilt, with simple and heartfelt phrases.
Where is the line between hope and hopeless? It’s blurred. The moment of profound change is clear only in retrospect, if then. After twenty-four hours? Forty-eight? Three months? Our job is not just about administering medicine; it’s also about managing expectations and treating the patient and the family, enabling them to accept the end. Some parts of the world make it simpler, empowering someone at a hospital to say, “It’s over.” But that’s not the way we do it here, at least right now. We do it case by case, doctor by doctor. And not all doctors are Dr. Martin.
When families can’t let go, technology can prolong the demise of a loved one at staggering emotional and financial costs. We possess the scientific ability to keep someone alive. But the cost of maintaining a person in that state indefinitely is in the millions, to say nothing of the emotional costs. Sometimes families choose to do so for reasons of denial, or religious beliefs, or misunderstanding, or simply because they feel they have no right to “kill” someone who is alive, even if only artificially. And there isn’t a lot we can do to stop it. That’s why Dr. Martin is so impressive. He doesn’t take away the family’s prerogatives, nor does he fuel false hopes. He presents reality in a way that enables them to let go.
Dr. Martin then lays out the process for Mrs. Werdna. “Everything will happen at your pace and timing. Now that we know he’s not going to wake up, we can disconnect some of the machines to create a more peaceful place, a little less beeping and buzzing. We can leave the room and you can visit with him by yourself, at peace. Some families prefer a day or two….” It’s clear that Mrs. Werdna is beginning to grasp the reality of her situation and accept the outcome. Nodding slowly, she says, “Doctor, you said he’s not going to wake up. I trust you. We don’t need any more time. I don’t want to drag it out. I just want him to be comfortable.” She turns to the neighbors. They all nod in agreement. She asks for a few moments alone with her husband, then says she’d like a chaplain to come in for a prayer. Then she thanks us again. We step into the hall. I notice that the resident, Dr. Young, is teary. She turns to me. “That was the most incredible family meeting I’ve ever seen. How do you guys know how to do that?” I shake my head. The fact is, I learned most of what I know in the last three days from watching Dr. Martin.
Our next step is to remove the life-support machinery. We have the staff shut down most of the scientific “noise”—the alarms and monitors—around Mr. Werdna and take the breathing tube out so he’ll look more familiar to his wife. The only equipment we leave is an EKG, because it will tell us when his heart stops beating. The staff also remakes the bed with a fresh blanket and pillows. The formality and the lack of medical clutter often help families say goodbye with dignity.
Mr. Werdna’s heart stops beating about fifteen minutes after care is formally withdrawn. The ICU nurse is the first to know it via the monitor at her station. She alerts me and the resident and asks me to pronounce him. Technically, Mr. Werdna isn’t dead until I have listened to his heart for a minute to ensure that there are no extra beats, watched him not breathe, and then written a confirming note in the chart. To me, these steps seem nonsensical, especially now, when the patient is unquestionably dead. I’m supposed to put a stethoscope on his chest as if I were listening for something that obviously isn’t there, which is cruel, since the families will reflexively hope for the impossible. A family member might ask with a tone of confusion and irrational hope, “What do you hear? What are you listening for?” I see Mrs. Werdna sitting right there, next to the bed, and I decide to sidestep the macabre ritual. I don’t touch the body or examine it. Instead, I look at the monitor at the station, see the flat line, then look at the EKG strip to confirm that it too is flat. The resident is watching when I pronounce Mr. Werdna officially dead: “He has passed. Time of death, 2:17 p.m.” Sometimes, following a protocol is not the right thing to do. Dead is dead. Worry about the living, the family. To me, this was the better way to do it.
—
One case. One doctor. One career moment. But these moments are something you have to keep in perspective. They’re rare. You can’t let the big moments overshadow everyday doctor work, or you’ll compromise your ability to deal with the average crisis. The CICU is full of serious cases, but we’re supposed to treat them all with the same gravity. The reality is, you have only so much emotional capacity. If a daughter says, “My father is light-headed,” you may think, “He’ll be fine; it’s probably nothing.” But it’s not fine or nothing to her or her father. You have to resist your own reflexes. It’s our job to separate these special moments from the everyday, but it’s counterintuitive.
You can’t walk out of a powerful end-of-life encounter and into the CICU to a patient who is sick, but not at death’s door, and treat her in an offhand or casual way: This is what I tell myself as I walk in to see a sixty-two-year-old woman with heart failure due to valvular disease. What she has is not immediately life-threatening, but she’s scared. We can medicate her and she’ll be okay. But she doesn’t know that. She thinks she could die. I talk. I explain. I listen. I read her signals. Am I getting through the way Dr. Martin did or even the way I did with Mrs. Werdna?
Throughout the next two weeks, I consciously invoke my mantra “Move on to the next patient. Focus. Move on to the next. Focus….” I want to treat all of these cases as important, not just the out-of-the-ordinary ones. But there’s the community hospital challenge of case mix. Plenty of people in the Bayview CICU (despite its name—cardiac intensive care unit) just aren’t that sick. You can move patients out of the unit once they’re ready for a regular medical floor, but you can’t control the inflow, the ones the ER doctors put there “just in case.” Hence the occasional Fellow’s crack, “Just saw a guy in the unit who’s in better shape than I am.” During the last week of the rotation, I see seven to ten patients a day, all told about forty-five patients. Two get stents. Two have open-heart procedures. Six are transferred to floors where they belong. Two die in the unit. Some are still there when I leave. I’m being a cardiologist—the day-to-day routine of practicing.
When I am away from the hospital, I try to put it in perspective, a hierarchy o
f what’s most important, what’s less so. I can never do it when I’m there. I run in the mornings and have conversations in my head. Did I handle that case right? Did the resident? What would I do differently next time?
On Friday, the final day of the rotation, Dr. Martin stops me in the hall for an end-of-rotation talk. He asks, “How do you think things have gone these last two weeks?” I don’t answer quickly, remembering how he uses waiting to make sure to say the right thing. “Dr. Martin, I’m not a sunshine blower or a yes-man, but I want to tell you that I really appreciate your approach….” I detail what I’ve learned, how his methods and style of communication made the rotation more significant, how it all made me a better Fellow, and how I want to challenge myself further as a result. When I finish, he’s surprisingly effusive: “Dan, you get it. You understand the complexity. You’re going to be very good with people. In fact, you already are.” He goes on, “The house staff likes working with you, and you’re well respected.” Then he offers, “If there’s anything I can do to help you in your career, I want to do it.” Medical training doesn’t have many moments such as this. Usually, it’s all classrooms, labs, clinics, charts, patients, and treatments—and being congratulated by one of the greatest teachers I’ve met so far is a meaningful moment for me.
This rotation opened my mind about Bayview and about drawing conclusions in general—both thanks to Dr. Martin. Here’s a physician who had world-class training and who then chose to practice at Bayview. And he practices very good medicine here. Just when I had all my prejudiced notions about how the branch office couldn’t measure up to the “real Hopkins” neatly in place, I end up having probably my best rotation experience. Lesson: Don’t make a diagnosis until you get all the information. I’ll carry it with me.
