"OK, Mrs. Brown, there's just one more
want to discuss before I leave you alone
I opened the chart and pretended to
always had trouble looking into my
during this part. Just stay cool, I
myself. This is your job. Nothing to
"Are you comfortable? Do you have any
about the medications we put you on or
the plan for
the next couple of days?" I was clearly
I'd already gone over it all three
times. I forced
myself to put the chart down.
"No," she replied. "I feel much better
doctor." I smiled glassily. That's
what made me hate
this so much.
"Mrs. Brown," I began, shuffling jerkily
her bed. "I need to ask you something."
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
OK." For just an instant I could see
waver. She sensed a "but."
"But if something should happen. Well,
more specifically, if your heart should
such that we would need to start
maybe even shock you, like on TV." The
definitely gone. "Not that I think
that's going to
happen. Not at all." I found my gaze
to the floor.
"Or if you stopped breathing for some
reason, which I also don't think will
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
"Are these things you would like us to
asked, handing her a blue mimeographed
piece of paper.
"Because if you don't, I'll need you to
She started to read, then stopped.
"What does this mean?" she asked. "It
My internship mainly consisted of one
uncomfortable episode after another.
of a loved one's death, dealing with
patients and staff and being vomited
unfortunately, rather common
However, the most disquieting part about
internship for me was meeting each new
patient, reassuring him that we had
facilities and were going to work very
hard to get him
better, and then asking him to sign a
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
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
After all, patients are admitted to the
either for a new and scary disease or an
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
situations, they'd rather have us help
them, or sit by
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
it, or at least not have it make my
hands sweat and my
But one would be wrong.
Still vivid in my memory is Ellen
87-year-old woman who weighed no more
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
episode of internal bleeding. The
was that she would not.
When I sat there on the nearly empty bed
at 2 a.m., though, seeing her shivering
beneath four blankets, scared to death
never see the outside of a hospital
again, I simply
could not bring myself to bring up the
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
undoubtedly dead. But I also thought
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
At 5:20 that morning, my beeper went
Terrified in the way that I always was
awakened by a loud noise, I looked at
number and recognized the sequence for a
jumped out of bed, trying to recall who
was in room
1102. But when I arrived to see 11
technicians, nurses and doctors in
around what looked like an empty bed, I
"What happened?" I asked my resident
"A-fib," she replied, never stopping the
compressions she was applying to Mrs.
chest. Atrial fibrillation -- her
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
the breathing tube into place, right
between her vocal
cords, and started pumping air through
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
all she needed was blood flow. Her lips
had turned a
"What's the story?" I looked up to see
attending, clearly still half asleep
despite his drive
in from home, taking up most of the door
"Eighty-seven, advanced unresectable
cancer in a-fib," replied a nurse,
filling the last of
six vials with blood that was to be
rushed down to the
"Does she want this?" he asked as a
X-ray machine the size of a tractor
dislodged him from
the doorway. Another nurse shrugged.
"No orders," she replied, and injected a
full of epinephrine in hopes of getting
the heart back
into a synchronous rhythm.
The next 30 minutes involved a set of
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
again, I'd be cleaning up the
colonoscopy suite for a
year. I didn't forget.
Of course, the odds wouldn't have been
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
This bothered me for quite some time.
the purpose of a waiver form is to give
the option of accepting or declining.
With my white
coat on, I knew I could sway the
whichever way I wanted, and that made me
But as the year went on and I continued
outgrow the old shoes of the med student
and began to
fit into my new ones as a doctor, I
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
patient. And after all, as a doctor,
that was my job.
So as my internship wound down, I still
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
as a patient advocate, by giving my
opinion as to whether it was likely that
and intubation would be helpful or
whether they would
artificially prolong a life that had,
for all intents
and purposes, ended.
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
the rest of his life? He was very sick,
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
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
If the medications didn't work, he would
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
This time he thought for a while longer.
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.
said. "That's fine." He signed.
I wasn't convinced that it was fine with
I knew it was right. The odds of him
through resuscitation to live any kind
thereafter was unbelievably small.
Several days passed, until one afternoon
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
to like this old man immensely. He had
once worked at
NASA, and was there for the original
space. He had been married to the same
I ran up to his room in intensive care
there to find it empty except for a
nurse watching his
monitor and the thin, frail man on the
"Mr. Weiner," I said, pulling a chair up
his head. "How do you feel?"
"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
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
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
looking even older than his 83 years.
wife was dead, and his son was on his
way in. Other
than the ever-slowing beep from the
everything was quiet.
I watched for half an hour, then an
hour, as his
heart gradually wore itself out. The
working. There was nothing I could do.
He kept his
eyes closed and didn't talk, saving
of energy to keep his heart going. But
it was a
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
give his heart muscle time to rest and
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,
think of anything else I could do. I
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
waiver, but if you tell me to do it now,
we can have
it going in 30 seconds." The eyes
I waited as the lines on his face
extra bit in thought. I wished he would
it was too late. The beeping on the
getting slower. I needed an answer.
"Mr. Weiner?" I asked, leaning over him,
ready to shake him to get an answer out.
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.
moment, he closed his eyes once more.
I sat back down and held his hand. The
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
"Thank you," he whispered, and closed
once again. I watched as the lines of
settled back into their natural pattern.
later, he was dead.
Every decision a doctor makes has the
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
doctor, the reason they go to him, in
the end, is so
he can make the correct decision -- the
Though only he knows, I believe that Mr.
appreciated the fact that he was not
tubes and machines and yelling and
at the end. He was glad to die
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
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
motivated more by emotion than by
That's when a doctor or, really, anyone,
I think, can
start to get into trouble.