That Good Night

by Sunita Puri

  “I know there seems to be endless talking, Teresa, but it’s because your dad’s situation is pretty complex, and we want to make sure that what we’re doing for him is what he’d want for himself.”

  “I’ll tell you exactly what we are going to tell you—do everything you can to save his life.” Teresa stared at me with her eyebrows raised and her arms folded across her chest. “But fine, if there’s no getting out of this, then let’s just meet tomorrow at noon.” Even though I understood that an intense jumble of emotions led Teresa to speak this way, I could feel my exasperation begin to outweigh my empathy for her. Just before leaving Joe’s room, I watched as she bent over him, moistening his brow with a cool towel, whispering that she loved him and would never leave his side. She pressed her forehead to his for a moment before removing her glasses and dabbing her eyes with a tissue. I set aside my frustration with Teresa and tried to look upon her as a loving and scared daughter, alone in a hospital room, unprepared to lose her father. Joan Didion’s words came to mind: “A single person is missing for you, and the whole world is empty.”

  * * *

  What People Might Mean When They Say

  They Want “Everything” Done:

  I want you to do all possible medical tests and procedures to cure my mother, all the things I see the doctors do on television, because those patients recover.

  If I don’t ask you to do everything, then I’m giving up on my father.

  I’ll sue you if you don’t do everything you can.

  I can’t be the one to tell the doctors to stop. I need to feel like I gave my father every chance to fight, even though I can’t answer you when you ask me what my father would want to fight for at this point. I don’t want to be the one to say “let’s just make him comfortable.”

  I feel guilty that I haven’t seen my aunt in ten years. But now that I’m here, I want her to get everything you can give her for her heart disease. Leave no stone unturned, no test undone, that sort of thing.

  I am so frightened that I’m going to lose my wife. What if she is the one-in-a-million person who will survive? How can you know for sure she’s going to die unless you try everything possible to keep her alive?

  If we don’t do everything we can to treat his cancer, isn’t it just like allowing him to die?

  Please, return her to me whole. Give me back the person I know and love.

  You’re not God. So who are you to say that you know for sure that he won’t survive a liver transplant? Do everything for him.

  I am overwhelmed, scared, worried, angry, confused, resentful, numb, unable to sleep, and deeply sad, and frankly it’s just easier for me to tell you to do everything than to have to take it in and digest the truth.

  Doctors told my father that he wasn’t going to survive his cancer but he told them he wanted everything done and he’s still here, three years later. I don’t trust what doctors say anymore. I want everything to be done for my mom.

  * * *

  During my fellowship, I might have spent hours with Teresa, convinced that if I heard and fully understood her opinions about her father’s care, I could gently refocus her attention on the gravity of her father’s neurologic devastation. I knew logically that her sharp words and adversarial attitude had nothing to do with me personally. But even just bearing witness on a daily basis to the strong emotions that accompanied death and loss dulled my own emotional response to the suffering that surrounded me.

  And yet, to take care of Mr. Brown, I’d have to find a way to talk to Teresa and her brother. A year ago, I might have asked how I could muster the fortitude to put up with Teresa’s behavior, her insistence on conflict rather than collaboration. Where I had once strived to be understanding with people like Teresa, I now grew impatient. I glanced at clocks during contentious family meetings. I cringed inwardly and tried to change the subject when a patient complained in great detail about how every physician they met had failed them. I’d force myself to listen to their monologues, waiting for a pause so that I could divert the discussion back to the topic at hand. I’d convinced myself that in order to do my job well, I had to forge an alliance with the Teresas I’d met. But now I began to ask myself a different question: What was my responsibility to patients if their families could not hear what I was saying no matter how many different ways I tried? Could I use compassion to soften their anger, and what might that look like? Would it be more compassionate to indulge avoidance of a tough discussion, or to force it?

  Despite meeting Teresa just once, my frustration with her swelled like a tide that threatened to engulf me. In retrospect, I can see that when I heard her voice, I also heard the chorus of difficult patients and families I’d encountered over the past two years, the ones whose anger I remembered more than their vulnerability. Teresa, her brother, and her father appeared in my mind as though I looked at their reflection in a fun-house mirror: Teresa, angry and controlling and unrelenting, was outsized, both tall and wide, inescapable. Mr. Brown, who was really the central character in this unfortunate drama, was short and squat, squished to the side by Teresa’s largeness. What was reflected back to me in this distorted image, the product of my frustration and impatience, was my own distorted sense of victimhood. Mr. Brown’s suffering, which I told myself was my focus, was not a part of this picture.

  * * *

  I had intended my move to Los Angeles to be permanent, a placement of roots firmly in the ground. But at first, permanence—or the hope for it—was an unexpected challenge. After all, transience had characterized the past ten years of my life. I cycled through everything from teams, patients, hospitals, clinics, apartments, pager numbers, and furniture. If stability was the intended payoff of all the transience, why did it feel like such a difficult adjustment?

  Just around the time I met Teresa and her father, I had started to feel just as comfortable outside the hospital as I did within its walls. Making friends in Los Angeles became easier. I worked closely with the hospital medicine physicians, many of whom consulted me regularly. They were a lively group with great senses of humor, appreciative of my work and sympathetic to the challenges it brought my way. They began to invite me to happy hours at local bars, Christmas parties at their homes, and departmental picnics. A number of them were around my age and had recently finished their own training; they could relate to the jarring adjustment of becoming an attending, and the curious discomfort of having newly free time to fill after training had ended. Over drinks and dinners, we talked about the more challenging parts of our jobs and the fun things to do in LA that made coming back to work easier.

  I gradually settled into a routine in my neighborhood. I found several welcoming coffee shops where I read and wrote, and a handful of restaurants that I explored with new friends from work. I hiked in Griffith Park with my brother, who had begun his residency training at UCLA. And I met a man whom I would come to love deeply. In the early days of our courtship, he would bring me Tupperware full of coffee cake he’d baked himself, and send me texts in the afternoons letting me know he was thinking of me. As was the case in residency, hours would pass before I’d reply. But he took no offense, telling me he didn’t send the notes with the expectation of an immediate reply. He just wanted me to know he was thinking of me, that was all. I found myself looking forward to the texts, scrolling through our conversations from start to finish when I took breaks from writing my patient notes, warming to the idea of someone I missed who missed me equally.

  This life, the beginning of what I’d hoped would be the permanence I’d craved, had for so long been a shimmering mirage at the end of the long road of training. As it came into sharper focus, I could feel some of my long-held anxieties about whether I was a good enough doctor begin to soften. Perhaps the best way to be a good doctor, I was learning, was for me to revel in everything outside of medicine, everything I’d wanted but never really believed I could have. The task now was to pro
tect it from the long shadows that work—particularly thorny situations like the one at hand with Teresa—could cast.

  * * *

  I struggled to find a place to meet with Teresa and Ray. They trailed behind me as I stopped first at the waiting room (full of visitors, two with young babies who wailed), then at a peach-walled conference room (occupied by two nurses on break, one of whom responded with only an annoyed stare when I asked if I could use the room for a family meeting), and finally the tiny ICU conference room (where several colleagues were discussing a difficult case). I considered taking them to the cafeteria, which was usually empty around this time, but recognized my growing desperation and stopped. It was as though places to have family conferences were deliberately engineered out of hospital architecture. There were plenty of spaces for every possible procedure, but not for a conversation. Just then, I felt a buzz in my pocket and saw a text message from Dr. Coffey: Meet in the nursing conference room.

  The nurses had agreed to let us use the large conference room where they often had staff meetings. Surrounded by blue-gray walls, it housed a large tan table and chairs with plush seats and firm, supportive backs. Teresa and Ray filed in, followed by Dr. Coffey and me.

  “So the reason we are all here today is because we need to talk about your father’s medical condition,” Dr. Coffey began right after we all sat down, his impatience already apparent. He spoke directly, evenly, his hands clasped together on the table before him. “I think we all know each other by this point, so let’s skip introductions and get started.” I glanced at the clock: 1:30 p.m.

  “As you know, your father had pretty advanced heart failure for several years now, along with diabetes, and his kidneys weren’t working that well, probably because of both those issues.”

  Teresa cut in. “I’m going to stop you right there, sir. Because I don’t think that his diseases just got worse on their own. They got worse because my dad was totally neglected by his doctors.” She tapped her pen on the table to emphasize the end of her sentence, glaring first at Dr. Coffey and then at me. “Now what I’m interested in is telling you all the ways that mishaps by his other doctors led us to this situation, and then you can tell me what your plan is to correct it.” She opened up one of her notebooks.

  “Um, Teresa, we’ve talked about this before and I don’t think it’s ultimately helpful to your father if we go over things that happened months and years ago, because he’s in a very different situation now and I—”

  “Yes, he is,” Teresa interrupted, raising her voice slightly, “and I want to see how you are going to correct all the things that weren’t done properly before. There is no way I’m going to let my father die because of all the screwups by the doctors here.”

  A type of filibustering followed for the next hour. Teresa talked about every detail of her father’s care except his current situation, which she talked around. There were the times the nurse in cardiology clinic had told him medications were ready for pickup from the pharmacy when they weren’t. There was the time his kidney doctor didn’t return Teresa’s phone call to confirm the next follow-up appointment day and time. Once, his primary care doctor suggested that he start a medication he was already taking. Teresa wondered aloud why doctors like us were paid so much when we couldn’t call patients back or remember the details of their treatment plans.

  “People sometimes feel like they need to go over every detail of everything that has gone wrong because they are hurt and angry and can’t cope with the situation,” Dr. Nguyen told me when I asked her how she sat through a similarly lengthy monologue during a family meeting once. “You just need to listen and try to remember that you’re there to help them try to think about what their relative would say is best for them.” I tried to pay attention as Teresa spoke, reminding myself that she was simply overwhelmed, that the combination of frustration, fear, anger, and grief she was expressing was understandable. Yet by making it nearly impossible for us to have an honest discussion with her, she was making it harder for us to care properly for her father—the person who mattered the most.

  Ray, who had been silent, spoke when Teresa paused after speaking for nearly twenty minutes. “I can’t believe all the ways my dad was treated not even like a human for so long. I didn’t even know all this stuff Teresa is telling you. Now that I know it, I’m asking myself, well, what can we do to correct this situation? Why isn’t that what you all are asking yourselves?”

  Ray’s tone became harsher and louder as he accused us of trying to euthanize his father and save the hospital system money. I wondered whether his words were an expression of his grief or whether he truly felt that this was the most effective way to advocate for his father to receive the best possible care. I wondered what Teresa and Ray were really asking for, and what they hoped we could do for them, for their father.

  This gridlock stalled Mr. Brown’s care. I looked on as Dr. Coffey tried to explain at least three different ways that Mr. Brown’s maladies had always been incurable but well addressed by his doctors; that unreturned phone calls and an hours-long delay in receiving a prescription for routine medications, while understandably aggravating, were not the reasons for his massive stroke; that he thought Teresa and Ray should simply consider the possibility of allowing their father a peaceful death, since his chances of survival were extremely small. But Dr. Coffey couldn’t make it through his sentences without fiery interruptions. He could never get to the part where he’d say he’d support their decision either way, but wanted to be sure they knew all the details of their options so they could discern which one their father would choose if he could.

  And the brighter Teresa and Ray’s anger burned, the less interested Dr. Coffey became in returning to the conversation’s original purpose. Eventually he grew silent, glancing at the clock on the wall. Silence, he would tell me later, was his only real option. Challenging Teresa would have weakened his ability to have any further conversations with her, should the need arise. His face, once concerned, had relaxed into apathy. These were exactly the types of situations that made many physicians wary of difficult conversations with patients and families. After all, it was far easier to do whatever a difficult patient or family requested than to help them understand that their request might be impossible or dangerous or the cause of tremendous suffering. It wasn’t right, but it was human.

  My idealistic side wondered whether there was a way I could cut through Teresa and Ray’s resentment of their father’s physicians and appeal to their love for him? The tired part of me wondered whether it was really my responsibility to understand and work with their anger.

  “I know that this has been a really tough ordeal for you both, tougher than any of us can imagine,” I said softly. Teresa snorted. Ray looked down at his lap. “We aren’t trying to gloss over the way your father’s care might have been handled in the past, but we do think it’s important to try to talk about how he’s doing now.”

  Teresa started laughing and Ray shook his head. “Have you been listening at all?” Teresa replied. “Or do you need some hearing aids? We understand how he’s doing. We know that this wouldn’t have happened if you people hadn’t fucked up. What we are respectfully asking you, on behalf of my father, is to do everything you can to fix him!”

  My anger—not my empathy—got the best of me.

  “You’ve said that many times, that we should do everything we can for your father. What we are trying to explain is that there are different ways we can care for your father, different ways that we can do everything for him, depending on what he would consider most important at this time,” I said, narrowing my eyes. “You’ve already heard this, but I want to be one hundred percent sure that we both have the same information about his condition. He’s had a major stroke, and we are worried that he may never wake up, talk, or be in any way independent again because he’s shown no signs of improvement in a timeframe when many other patients would have started to open t
heir eyes or move. In addition to this stroke, he’s suffered from heart failure and diabetes, and these conditions might make it even harder for him to survive his stroke.”

  “Wait, wait, wait,” Teresa interrupted. “Why are we going back to this? The heart failure, the diabetes—that has nothing to do with this stroke. Those are problems that you people caused.”

  “Sister, shut up and let her talk,” Ray said. “I really want to hear what this one has to say about Dad’s so-called options. Even though we keep saying the only option is for him to keep fighting.”

  I paused, considering whether I should continue. But remaining silent angered me more than the prospect of further confrontation frightened me. No matter what Teresa and Ray’s response might be, I felt responsible for telling them about the same options that any patient in Mr. Brown’s position would be given.

  “Actually, before we get into options, I want to learn more about something you’ve both said. You describe your dad as a fighter who would want everything done for him. Can you tell me what that means to you? These are words that mean different things to different people.”

  Ray laughed and Teresa shook her head. “You went through so much school and you’re asking me what I mean when I say Dad is a fighter?”

  “Yes,” I said. “I want to hear what you understand the fight to be, and what you’re envisioning the outcome will look like if he wins this fight.”