The hardest question

Even after doing it hundreds of times, it's never easy to ask someone whether they want you to let them die.


Jeff Drayer
March 27, 2000 10:00PM (UTC)

"OK, Mrs. Brown, there's just one more
thing I
want to discuss before I leave you alone
for the
night."

I opened the chart and pretended to
read. I
always had trouble looking into my
patients' eyes
during this part. Just stay cool, I
thought to
myself. This is your job. Nothing to
worry about.

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"Are you comfortable? Do you have any
questions
about the medications we put you on or
the plan for
the next couple of days?" I was clearly
stalling now.
I'd already gone over it all three
times. I forced
myself to put the chart down.

"No," she replied. "I feel much better
now,
doctor." I smiled glassily. That's
what made me hate
this so much.

"Mrs. Brown," I began, shuffling jerkily
toward
her bed. "I need to ask you something."
Her smile
bade me continue. "Now, we think you're
going to do
just fine and I don't think anything bad
is going to
happen. We know what's wrong and we
know how to treat
this. I think everything's going to be
absolutely
OK." For just an instant I could see
the smile
waver. She sensed a "but."

"But if something should happen. Well,
I mean,
more specifically, if your heart should
stop beating,
such that we would need to start
compressions and
maybe even shock you, like on TV." The
smile was
definitely gone. "Not that I think
that's going to
happen. Not at all." I found my gaze
drifting down
to the floor.

"Or if you stopped breathing for some
strange
reason, which I also don't think will
happen, and
needed to be put on a breathing machine
which we may
never be able to take you off of." I
forced my eyes
back to her face. It was wrapped in
confusion and
increasing dismay.

"Are these things you would like us to
do?" I
asked, handing her a blue mimeographed
piece of paper.
"Because if you don't, I'll need you to
sign this."
She started to read, then stopped.

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"What does this mean?" she asked. "It
just says
DNR/DNI."

My internship mainly consisted of one
uncomfortable episode after another.
Informing people
of a loved one's death, dealing with
difficult
patients and staff and being vomited
upon were,
unfortunately, rather common
occurrences.

However, the most disquieting part about
internship for me was meeting each new
patient, reassuring him that we had
state-of-the-art
facilities and were going to work very
hard to get him
better, and then asking him to sign a
waiver saying
whether or not he would desire treatment
in case his
heart stopped or he couldn't breathe.

As the member of the medical team who
knew the
least (except when we had med students
on the team,
and even then it was a tossup), it
always fell to me
to perform the delicate task of
discussing do not
resuscitate/do not intubate orders. It
was a job I
feared.

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After all, patients are admitted to the
hospital
either for a new and scary disease or an
old familiar
one that may finally be getting the
better of them.
It takes a lot of work to calm them down
and make them
feel safe, which is not just nice for
the patient but
can actually affect the course of their
hospitalization. And once this tenuous
bond of trust
is forged, about the best way for a
doctor to screw it
up is by asking a patient if, in the
scariest of
situations, they'd rather have us help
them, or sit by
and watch.

That's what I had to do, usually about
seven times per night when on call, two
times a day
otherwise. One would think that I'd get
good at
it, or at least not have it make my
hands sweat and my
voice shake.

But one would be wrong.

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Still vivid in my memory is Ellen
Greenwood, an
87-year-old woman who weighed no more
than 70
pounds. She was dying of stomach
cancer, and there
was nothing that could be done other
than try to make
her comfortable and see if she'd make it
through this
episode of internal bleeding. The
prevailing thought
was that she would not.

When I sat there on the nearly empty bed
with her
at 2 a.m., though, seeing her shivering
beneath four blankets, scared to death
that she'd
never see the outside of a hospital
again, I simply
could not bring myself to bring up the
DNR/DNI form.
I knew that without it, we would be
legally bound, in
the case of an emergency, to perform
heroic action for
as long as it took until she was
absolutely,
undoubtedly dead. But I also thought
that discussing
the possibility of her heart suddenly
stopping or her
breath no longer coming to her could
cause her to have
a heart attack right there on the spot.
So I held
off. She'd at least make it through the
night, I
thought.

At 5:20 that morning, my beeper went
off.
Terrified in the way that I always was
when being
awakened by a loud noise, I looked at
the call-back
number and recognized the sequence for a
"code." I
jumped out of bed, trying to recall who
was in room
1102. But when I arrived to see 11
respiratory
technicians, nurses and doctors in
frenzied activity
around what looked like an empty bed, I
remembered.

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"What happened?" I asked my resident
breathlessly.

"A-fib," she replied, never stopping the
rhythmic
compressions she was applying to Mrs.
Greenwood's
chest. Atrial fibrillation -- her
ventricles were
squeezing in a random, uncontrolled
pattern that would
not push blood through her body. I took
my place at
the head of the bed.

With some help from the respiratory tech
I got
the breathing tube into place, right
between her vocal
cords, and started pumping air through
it with
rhythmic squeezes of the big, blue
oxygen bag. Air
movement could be heard on both sides of
the chest, so
we knew she was getting the oxygen she
needed. Now
all she needed was blood flow. Her lips
had turned a
purplish blue.

"What's the story?" I looked up to see
my
attending, clearly still half asleep
despite his drive
in from home, taking up most of the door
frame.

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"Eighty-seven, advanced unresectable
stomach
cancer in a-fib," replied a nurse,
filling the last of
six vials with blood that was to be
rushed down to the
lab.

"Does she want this?" he asked as a
portable
X-ray machine the size of a tractor
dislodged him from
the doorway. Another nurse shrugged.

"No orders," she replied, and injected a
syringe
full of epinephrine in hopes of getting
the heart back
into a synchronous rhythm.

The next 30 minutes involved a set of
clearly
futile activities surrounding Mrs.
Greenwood, not the
least of which was my attending
screaming at me the
entire time that so help him God, if I
ever forgot to
discuss DNR right when a patient was
being admitted
again, I'd be cleaning up the
colonoscopy suite for a
year. I didn't forget.

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Of course, the odds wouldn't have been
bad that
Mrs. Greenwood would not have signed
such a waiver.
Most patients watch people getting
healed by electric
shock and miraculous injections on TV
all the time.
What my attending really meant wasn't so
much that he
wanted me to get my patients' opinions
as that he
wanted me to convince those people who
were very, very
sick to sign the form and give away
their right to
heroic measures.

This bothered me for quite some time.
After all,
the purpose of a waiver form is to give
the patient
the option of accepting or declining.
With my white
coat on, I knew I could sway the
patient's opinion
whichever way I wanted, and that made me
feel
uncomfortable.

But as the year went on and I continued
to
outgrow the old shoes of the med student
and began to
fit into my new ones as a doctor, I
realized
that this was not an issue of me forcing
my opinion on
somebody, but rather me making just
another of what
would be dozens of clinical judgments on
each
patient. And after all, as a doctor,
that was my job.

So as my internship wound down, I still
found a
heavy feeling in my stomach and beads of
sweat on my
forehead every time I broached the
subject with a new
patient. But I did come to take a more
active role
as a patient advocate, by giving my
professional
opinion as to whether it was likely that
resuscitation
and intubation would be helpful or
whether they would
artificially prolong a life that had,
for all intents
and purposes, ended.

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On one of my last on-call nights I
admitted a frail
83-year-old man who had suffered his
second mild heart
attack in two weeks. He was friendly
and outgoing and
talked to me of his great-grandchildren
for quite some
time before I decided to pop the
question. If his
heart stopped beating or he couldn't
breathe, did he
want us to take every measure we could
to get him
going again, even if it meant being on a
ventilator
the rest of his life? He was very sick,
I reminded
him. I had checked his EKG, and it
showed a very
ominous pattern. He was in extremely
poor health. He
paused and thought, for only a moment.
"Why yes, of
course."

I explained that we would be giving him
a lot of
good medications, but that he was too
old and had too
much kidney disease to allow us to
perform surgery.
If the medications didn't work, he would
die anyway,
since they were his only option. If he
started to die
and we revived him, he would still be
left with only
the same medications, but he would be
hooked up to
machines, totally incapacitated. Was he
sure he
wanted that?

This time he thought for a while longer.
I
provided a firm, reassuring nod each
time he looked at
me. After quite some deliberation, he
finally let out
a long, low sigh, and nodded his head.
"OK," he
said. "That's fine." He signed.

I wasn't convinced that it was fine with
him, but
I knew it was right. The odds of him
making it
through resuscitation to live any kind
of life
thereafter was unbelievably small.

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Several days passed, until one afternoon
my
beeper called me out of a lecture.
"It's Mr. Weiner,"
the nurse said. "He's failing."

My heart sank. In the past few days I
had grown
to like this old man immensely. He had
once worked at
NASA, and was there for the original
flight into
space. He had been married to the same
woman for
53 years.

I ran up to his room in intensive care
and got
there to find it empty except for a
nurse watching his
monitor and the thin, frail man on the
bed.

"Mr. Weiner," I said, pulling a chair up
next to
his head. "How do you feel?"

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"I pushed 60 of lasix," to try to rid him of some of the extra fluid collecting in his lungs, the nurse
reported. Mr. Weiner
simply shook his
head.

His heart, weakened by the heart
attacks, was no
longer able to push the blood around his
body. It had been trying to make up for
it by beating
faster, but the muscle had clearly tired
out, and
there was little else we could do. I
checked the rate
of his IV medication, designed to make
his heart pump
as forcefully as it could. It was
dripping out as
fast as possible. There was nothing
left to do.

I watched as he lay there alone, his
face pale,
looking even older than his 83 years.
His
wife was dead, and his son was on his
way in. Other
than the ever-slowing beep from the
cardiac monitor,
everything was quiet.

I watched for half an hour, then an
hour, as his
heart gradually wore itself out. The
medicine wasn't
working. There was nothing I could do.
He kept his
eyes closed and didn't talk, saving
every ounce
of energy to keep his heart going. But
it was a
losing battle.

I continued to watch, but could only
think of one
thing. I could push his heart for him.

It would circulate the blood to his
body, and
give his heart muscle time to rest and
recuperate. It
wouldn't have to be for long, but it
would give him
enough time to build up more strength.
I knew inside
that it wouldn't matter -- his heart
would just tire out
again, half an hour later. It would
only prolong the
pain. But as I sat there and watched,
saw the lines
of pain slowly creeping across his face,
I couldn't
think of anything else I could do. I
squeezed his
hand, and he opened his eyes to slits.

"Mr. Weiner," I said softly. "I can
call a code.
We can do compressions and make your
heart beat for
you." He didn't answer. "I know you
signed the
waiver, but if you tell me to do it now,
we can have
it going in 30 seconds." The eyes
closed.

I waited as the lines on his face
crinkled an
extra bit in thought. I wished he would
hurry, before
it was too late. The beeping on the
monitor was
getting slower. I needed an answer.

"Mr. Weiner?" I asked, leaning over him,
almost
ready to shake him to get an answer out.
He opened
his eyes again, this time all the way.

"Mr. Weiner?" He looked at me for a
moment, and then slowly,
ever so slowly, shook his head no.
After another
moment, he closed his eyes once more.

I sat back down and held his hand. The
beeping
grew slower still. Then I heard a new
sound, like a
box whose hinges needed oil being
opened. I looked,
and his mouth was ajar. I leaned
forward.

"Thank you," he whispered, and closed
his mouth
once again. I watched as the lines of
his face
settled back into their natural pattern.
Ten minutes
later, he was dead.

Every decision a doctor makes has the
potential
to be emotional. As someone with
many years of
training in exactly the right measures
to take in each
specific situation, I have worked hard
to make the
unemotional, "correct" decision. But as
a human being
who often comes to genuinely like his
patients, it is
easy to let my emotions take over.

Although people want to be liked by
their
doctor, the reason they go to him, in
the end, is so
he can make the correct decision -- the
rational one.
Though only he knows, I believe that Mr.
Weiner
appreciated the fact that he was not
surrounded by
tubes and machines and yelling and
frenzied activity
at the end. He was glad to die
peacefully. Despite
the minuscule chance it would have
worked, he was
happy I had convinced him to become DNR.

I still think about Mr. Weiner from time
to time.
Not because he was funny or because he
was brave or
because I knew him very well. I
remember him when I
find myself afraid to discuss some
delicate issue with
a patient or when I am about to do
something
motivated more by emotion than by
rational thought.
That's when a doctor or, really, anyone,
I think, can
start to get into trouble.


Jeff Drayer

Jeff Drayer is the author of "The Cost-Effective Use of Leeches and Other Musings of a Medical School Survivor." He lives in Boston, where he is doing a dermatology residency.

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