That Good Night

by Sunita Puri

  “Well, that’s the difference in thinking between an intern and a resident,” he replied. “You and I both know where Ryan and Erin are coming from. Maybe in another patient, or the Mr. Smith from a year ago, we’d treat the clot. But we can both see that Mr. Smith’s confusion is the beginning of dying from his terrible cancer. I agree with you—let’s just treat any pain or shortness of breath he has tonight and try to get him home in the morning.”

  I unclenched my fists, relieved that he agreed with me, but also acutely aware of the gravity of my plan for Mr. Smith. “I was worried you would think I’m a bad doctor,” I confessed. I immediately regretted being so forthcoming about my insecurity. “Not at all,” Dr. Doyle said. “I think it’s far more difficult to recognize when we need to step back and allow nature to take its course than it is to just start treating any and every problem.” I let his words sink in, and thanked him.

  After our call, I wrote something like this in Mr. Smith’s chart: “The risks of anticoagulation outweigh the benefits in Mr. Smith, as he has sustained a recent GI bleed and has a limited life expectancy due to his metastatic esophageal cancer. I will order medications to treat his shortness of breath and confusion, and will arrange his discharge back to his home nursing facility with hospice services in the morning.” Instead of reducing his situation to a series of medical abbreviations and half sentences as I did in most patient notes, I wrote about him in paragraphs, as though complete sentences in his chart could somehow add a measure of dignity to a man dying alone. Instead of ordering medications to treat his blood clot, I ordered medications to treat his shortness of breath. I asked to space out the checks of his vital signs to minimize disturbance of his sleep. I requested no further lab draws. I signed these orders and called Ryan to let him know of the change in plan. “Okay,” he said quietly. “I guess we’ll see how he’s doing in the morning.”

  I continued to stare at the computer screen after hanging up the phone.

  * * *

  I spent the next few hours checking on each of my patients, reexamining them if needed, adjusting medication doses, speaking with their family members. It was two a.m. when I retreated to my overnight call room.

  I had not been paged for thirty minutes, the longest stretch of respite that day. I lay down on the saggy call room bed and closed my eyes. I could still see the image of the computer screen in my head, the orders I had signed seemingly pinned to the lining of my eyelids. I thought of how difficult it had been to tell Ryan that I’d decided not to give Mr. Smith heparin, even though Dr. Doyle had agreed with my decision. Disagreements between colleagues about serious decisions for patients could sting, as I had learned from my mother.

  I was nine years old when she first began to tell me about the decisions she struggled to make at work, especially if her opinions were at odds with those of her colleagues in surgery. She would sit on our gray-and-black-striped couch and I would sit on the carpet, closing my eyes as she brushed the unruly frizz that was my hair at the time, smoothing it with coconut oil, weaving it into a braid. My head was tilted back from the cumulative force of brushstrokes, my eyes fixed on the white puffs that lined our ceiling, reminding me of vanilla cake crumbs. While she brushed, she told me her schedule that day: “Today I have two cases with one surgeon, then I have to help out in the clinic in the afternoon.” Her usual honeyed voice, a mixture of English and Hindi, was replaced by a detached evenness, a tone that I didn’t yet know I would adopt years later: the doctorly tone. As I heard her talk about work, I wondered why her voice changed.

  She set the brush down and picked up the blue bottle of coconut oil from Asia Sweets and Spices, the only Indian grocery store within driving distance of our home. It was the only place at the time that carried staples we needed: coconut oil, saffron, giant cardamom that my mother kept in the freezer, bootleg videotapes of old Hindi movies and the newly released Ramayana, calling cards to India, Ayurvedic toothpaste, velvety red bindis that my mother wore to prayers and parties, and, behind a glass counter, a multicolored assortment of the Indian sweets my parents loved.

  Her hands, small and soft, massaged the drops of oil first into my scalp and quickly down to the last stretch of my hair, pausing at the end to massage her own hands with the traces of oil that remained.

  “This surgeon always wants to do very aggressive operations I don’t think we should be doing. One of the cases is a guy who is ninety. He has so many problems already with his heart and lungs, and now he broke his hip and the surgeon wants to fix it.”

  I was still looking at our ceiling, wondering whether the big earthquake I kept hearing about at school would cause the flecks of white to flutter down in the closest thing to snowfall I’d probably ever see in Los Angeles. “I don’t think it’s right,” my mother continued. “His heart and lungs are badly failing and you want to do a surgery?” I felt her hands moving rhythmically between the three sections of my hair, weaving them together, stopping, reinforcing what she had already braided, and continuing. “I really don’t think we should be doing this but it is hard to argue with the surgeon.”

  She tied a purple scrunchie to the base of my braid and stood up. “Time to go,” she said.

  It would be years before I understood the complexity of the relationship between anesthesiologists and surgeons, but even as a child I could sense the normalcy of professional disagreements—with their occasionally serious consequences—during my mother’s workdays. I wonder now why she began telling me these stories when she did, when I sat at her feet and she could only see my back, not my face. Maybe it wasn’t me she was speaking to. Maybe it was just herself. Maybe there was something about the simplicity of braiding your child’s hair, of trying to tame it, that enabled her to say out loud how tough it was to bring order to the chaos in which she worked.

  I now wished there was something I could do to slow the tumble of repetitive thoughts in my head. Was Mr. Smith actually dying? Could I know that for sure unless I tried treating what might be treatable? Yet why did the mere thought of trying that feel nauseating? Did I do a good enough job of translating my gut reaction, the combination of sickening nausea and sinking of my stomach that arose when I thought of thinning his blood and placing him on a breathing machine, into a rigorous and intellectual care plan? Was I being doctorly rather than emotional?

  I was midway through a yawn when my pager let out a series of beeps from Mr. Smith’s nurse. “His breathing has changed,” she said worriedly when I called her back. “Please come evaluate him.”

  Dying has a certain cadence and tempo, which is a recognizable prelude to an infinite stillness. When I first entered his room, Mr. Smith looked like he was sleeping. His chest rose and fell intermittently, then more slowly. His eyes remained closed when I shook his shoulder. His heart rate slowed. The tempo increased.

  A hot wave of panic moved through me. Every contour of my stomach burned. I hadn’t expected him to die tonight. Had my inaction expedited his death? Could heparin have helped him have a few more good days? I pulled up a chair to the side of his bed and sat down.

  There was nobody to call on his behalf. There was nothing to do but be there. Goosebumps lined Mr. Smith’s arms, and I covered him with warm blankets from the ICU one floor above him. I moistened his drying lips with artificial saliva. Remembering a note referencing his love of folk music, I used my phone to play bluegrass tunes, dispelling the heavy silence around us with banjo, guitar, and pensive lyrics.

  I reread his tattoo. Where there is light there must be darkness. All the light and promise of modern medicine, inseparable from its dark potential for suffering.

  At three a.m. I held the hand of a stranger. I watched his lungs expand and release air first in great heaves and then in diminished puffs, felt his pulse race and then suddenly slow, looked at his beard and tangled hair and wondered when he last took a shower, when anyone held his hand for this long, whether he would have wanted company or s
olitude. For a minute, our pulse rates were the same. When it became difficult for me to tell whose pulse I was feeling, I kept my hand on his wrist and placed my other hand against the juncture of my neck and head, noticing that my carotid pulse matched his radial pulse, that in this way, for this stretch of time, the pulse of an exhausted resident and her dying patient matched precisely. And then his breathing pattern became irregular. His heart slowed again.

  The dark sky slowly gave way to the navy blue of early morning and the day’s first blush. As the sky brightened, Mr. Smith’s breathing slowed even more. At 6:37 a.m., he stopped breathing entirely. His body remained, but he had quietly and comfortably moved out, leaving behind his tattoo, his bruises, his clot, his cancer. I sat next to him for a few minutes before I rose and pressed my stethoscope against his still, silent chest.

  Ryan and Erin approached me shortly after arriving at the hospital to ask how our patients did overnight. “So Mr. Smith died just about forty-five minutes ago,” I said, almost as if I were confessing to a crime, forgoing our usual discussion of patients in alphabetical order. “What?” Erin exclaimed. “He went that fast? That clot must have been really big.” Ryan took a deep breath and looked at me. “Wow,” he said, shaking his head. “Don’t you think that maybe the heparin would have helped? He could maybe have gotten back to the nursing home instead of dying here.”

  “To be honest, I think he would have died either way, but he could have suffered more with the heparin if he bled,” I said, my temples throbbing with fatigue. “I went back and forth for a long time about whether or not to treat that clot. I actually agonized about it. I still am,” I said. “But I was with him when he died. And he looked peaceful. It was like he just fell asleep.”

  Ryan nodded and turned to his computer quietly, looking through the charts of the patients who survived the night.

  Rounds that morning were somber. “I’m surprised he went that quickly,” Dr. Doyle said. I nodded in agreement, feeling the first sting of tears at the corners of my eyes, pretending to sneeze so that I could secretly wipe them.

  Ryan and Erin looked at each other, and Ryan spoke. “I can’t shake the feeling that maybe the heparin would have been helpful.” I thought of my mother’s disagreements with her colleagues over the years, of how arguments over life-and-death decisions betrayed deeper divides about the purpose of medicine, how a doctor’s obligations to a patient straddled both existence and eternity.

  “Even if that’s what we had done, his time would have been very short,” Dr. Doyle said, “and the most important thing was that he was comfortable.” I wanted to feel more reassured by his words than I did. I half listened as Dr. Doyle redirected our conversation, reviewing the different ways to treat blood clots in the lungs depending on their size and severity. I couldn’t concentrate, my mind wandering back over every decision I had made as I learned each detail of Mr. Smith’s situation. Had I been right? I wondered. Had I been the doctor he needed me to be?

  As I drove home that afternoon, I realized that what troubled me was just how deeply ingrained my expectation was that I should keep patients alive no matter what. I expected Mr. Smith to die soon, though I struggled to accept that he was already in the process. And I didn’t want him to die on my watch. I initially found myself thinking more about fulfilling a certain professional obligation than recognizing the type of care Mr. Smith really needed from me. I thought of Ryan and Erin, who both seemed mildly traumatized to learn that Mr. Smith had died hours after he came to the hospital when there was something we could have done for him. Even though Dr. Doyle supported and even praised my decision making, their words made me second-guess myself nonetheless.

  Becoming comfortable with the inevitability of patients’ mortality seemed to rely on a certain unlearning of what I’d been taught in medical school about a doctor’s obligations to her patients. My responsibility wasn’t to keep Mr. Smith alive at all costs, though that’s what my mind tried to convince me. Though my profession relied on science to halt the ways that nature affects and afflicts the human body, perhaps it was equally important to realize when trying to outsmart nature would inflict a different sort of suffering on my patients. It seemed to me that one of my most important responsibilities would be to know and remind myself of this difference.

  Part 2

  THE UNLEARNING

  Five

  THE UNLEARNING

  On June 30, 2013, I completed my last day of internal medicine residency in San Francisco. Hours later, on July 1, I began my fellowship training in palliative medicine in Palo Alto. I’d spent most of June 30 driving back and forth between my old apartment in San Francisco and my new apartment in Burlingame, packing and dropping off boxes and bags I’d hastily filled with clothes and books. A quaint town midway between Palo Alto and San Francisco, Burlingame was home to a spacious tiled library, a main street lined with bakeries and restaurants, and an independent bookstore that stocked bestsellers and gossip magazines alike. I’d visited the town when I’d driven down to have dinner with an old friend who lived there with her husband. I liked the church steeple that came into view as I drove to my new home, an olive apartment complex set behind a garden filled with rosemary bushes and neatly arranged cacti. My street was home to trees adorned with leaves so green they seemed fluorescent; just a few months later, the same leaves would burn a deep burgundy. Across the way, a solitary willow bowed to the sky in reverence. Living here felt like respite. After making at least ten trips between the two cities in the span of a half day, I arrived at Stanford University Hospital bleary-eyed and lost, trying to make my way to the palliative care team office in the basement of the main hospital.

  Certain things would remain the same in both residency and fellowship. I would spend one-month blocks rotating between three different hospitals—the university hospital, the Palo Alto veterans hospital, and the county hospital. I still worked under the supervision of an attending physician, whose role it was to teach and mentor me, and who was ultimately responsible for the care of the patients I saw.

  But in many ways, my role had changed overnight. Instead of admitting patients from the emergency room and addressing all of their medical problems throughout their hospital stay, I saw patients only when another doctor requested a consultation for a patient, usually to treat certain symptoms (such as cancer pain, nausea, shortness of breath) and to talk with patients and families about their treatment goals—what patients considered most important and dear to them when living with a serious illness. I’d gone from assuming that many of my patients would live for years after their hospital stays to knowing that some of my patients would die within the coming weeks or months after returning home.

  After accidentally meandering into the cubicles of various social workers and the heart transplant team, I finally found the palliative care team’s cubicles. A petite woman with warm brown eyes and shoulder-length brown hair greeted me with a wide smile. “Hi, Sunita! It’s so nice to have you here! My name is Charlotte, and I’m the social worker on the team.” I wondered how she already knew my name, and noticed that someone had written on the whiteboard in red marker, “Welcome Sunita Puri to Stanford Palliative Care!”

  “It’s great to meet you, Charlotte!” I said, already sensing that she and I would become good friends.

  “Here, I printed you a list,” she said, handing me a roster of fifteen patients. “We just got a couple new referrals from the oncology team, but we’ll talk about them on rounds.”

  I scanned the list filled with patients’ names, ages, and diagnoses. There are some young patients here, I thought. Age twenty-one, lymphoma. Age forty-five, metastatic gastric cancer. Age thirty-five, ICU day thirty, acute respiratory distress syndrome.

  “Charlotte, are there patients on this list that I’m supposed to see before rounds?”

  “No, it’s your first day! So on our team we have two nurses and an attending physician and me. Everyone usually s
hows up for rounds at nine-thirty or so, and we will talk about each of the patients on our list. The attending this month is Dr. Harris, and she’ll assign you a few patients to see. Oh, and you’ll need that,” she said, motioning to a pager on the corner of my cubicle. “The teams will page you when there’s a new consult to see.”

  Charlotte showed me how to look up pager numbers on the hospital directory and told me what days of the week the cafeteria food was worth eating. She asked me where I was from and what brought me to Stanford, and showed me photos of her two children. “This rotation can be intense,” she mentioned in a low voice, “so please make sure you have some way to let off steam. And always let me know if you need anything.”

  Dr. Harris arrived shortly, followed by the two nurses on the team. A short woman with bouncy black hair cut to her shoulders, Dr. Harris wore the sort of conservatively stylish outfit you might find at Ann Taylor. Businesslike and efficient as she introduced herself, Dr. Harris told me that her day was packed with meetings, but that she would assign me several patients to see and we would talk about them later in the afternoon. “We tend to get quite a few consults, usually around four or five new ones each day in addition to the other patients we are already seeing. You will definitely see a lot this month,” she told me.

  I listened as the team discussed each of the patients on our list. The twenty-one-year-old’s lymphoma was getting worse, as was her bone pain and kidney failure. The forty-five-year-old wanted to go home with hospice care but his wife told him she refused to let him give up on his life. The thirty-five-year-old had a high fever overnight and the ICU team suspected he had a new pneumonia. Almost all of our patients required family meetings, and some also required better control of pain. Everyone was open to the suggestions of others; Dr. Harris suggested what medications and doses the nurses should use for patients in significant physical distress, and Charlotte offered ways to discuss hospice constructively with the forty-five-year-old patient’s wife. The discussion was thorough but matter-of-fact, devoid of emotion. Then again, I thought, for this sort of work to be sustainable, maybe it must also become routine.