Courting Death

by Paul Heald

  Perez frowned, not at the difficulty of the question, but with impatience at having to spell out what he saw as obvious. “I have been dealing with cranial trauma victims for eighteen years now. I have never seen a patient with your father’s injuries ever emerge from a coma with significant cognitive function.”

  The finality of this prognosis pushed Sally over the edge. She leaned against Terri and cried uncontrollably.

  “But I saw his foot move! You’re not God—you don’t know what’s going to happen.” Buddy shouted at the doctor.

  “What about your colleagues’ patients or case histories that you’ve read about in journals or textbooks?” Arthur asked, thinking that his younger brother should hear the worst.

  “We’ve all heard of miracle cases,” Perez sighed as he shook his head and turned for the door, “but I think they are always explained more convincingly in terms of monitor malfunction rather than spontaneous regeneration of brain activity. But anything is possible, I suppose.” He opened the door and escaped awkwardly. Terri held Sally and rubbed her back gently as she struggled to get a hold of herself. Buddy closed his eyes tightly and rocked himself back and forth in small, measured motions like an autistic child. No one found any words to cut through the despair that permeated the room.

  The door opened again after a few minutes and a middle-aged woman wearing a name tag embossed “Leslie Blackwell, Critical Care Liaison” sat down at the conference room table. Her conservative gray skirt and matching blazer made her look more like an attorney than a nurse but her demeanor was not coldly businesslike. She fairly radiated empathy and concern as she took the seat that Dr. Perez had occupied.

  “I know this is a very difficult time, but the doctor wanted me to speak with all of you together. My name is Leslie, and I’m not a nurse or a doctor, but a social worker whose job it is to help the families of patients deal with the difficult medical decisions they have to make.” Arthur wondered how she would deal with his brother. “Now, I need to ask you some questions that will help our staff determine how aggressively your father will be treated.”

  Buddy opened his eyes.

  “First of all, we need to know whether he ever executed any sort of living will or any other type of witnessed document in which he spelled out what sort of treatment he wanted to receive in the event of a terrible accident like this one.” Terri and Arthur looked at their mother, who shook her head. Ms. Blackwell explained that without a living will, some options, such as ceasing tube feeding, were not available.

  “Why the hell would we want to stop feeding him?”

  Blackwell nodded at Buddy to acknowledge his question. “You can decide to give your father the benefit of every heroic measure modern medicine can offer, but many families are quite adamant about letting nature take its course when there is no hope of a recovery.” She spoke unapologetically, directing her soothing voice at Buddy, but glancing casually at Terri and Arthur to see if they too were likely antagonists.

  “Well, this is one family that’s not going to kill their father, especially when the doctor says that anything is possible.” Buddy’s glare would have paralyzed a less experienced woman.

  “Exactly what did Dr. Perez say about your father’s chances for recovery?” She looked slightly perplexed.

  “The doctor gave us no hope short of a miracle, which he himself didn’t seem to believe in.”

  Terri nodded in agreement with Arthur’s summary.

  Buddy muttered something under his breathe about not giving up hope.

  “It’s not my job to tell you whether to hope, or not to hope, or what to hope for.” She spoke quietly, resting the tips of her fingers on the table in front of her. “I do know that your father is injured badly enough that Dr. Perez is willing to consider several different treatment options. Any decisions must ultimately be made by Mrs. Hughes, but he thought that the children should be informed to help her think things through.” They were all attentive now; even Sally had raised her head, her puffy eyes fixing on Blackwell’s name tag for the first time. “You’ve all seen your father. Right now, we are doing everything we can to keep him alive. Although his brain has been severely damaged, his vital signs are fairly strong, and he may soon be able to breathe without a respirator. He might continue in this vegetative state for months or maybe even years, or he might develop complications tonight and pass tomorrow.

  “In accordance with hospital procedure, I have checked your father’s insurance. It’s adequate for the short-term, even with his care here in the ICU running over two thousand dollars a day. Were he to live more than a couple of months, however, you would be facing severe financial hardship.”

  “Mrs. Hughes,” she addressed Arthur’s mother directly for the first time, “you may want us to sustain your husband as he is indefinitely, but at your request, we could cease treating him quite as aggressively as we have been. As I mentioned before, we cannot stop providing food and water, but over the next couple of days, your husband is likely to suffer from two conditions very common to patients with his sort of injuries. To be specific, the doctor said he would be very surprised if a post-operative pericardial infection did not set in. He also believes that pressure on the brain caused by its own swelling will increase dangerously.

  “Both of these conditions are life threatening. If left untreated, his chances of survival are slim. The severity of the injury to his brain—the fact that he’s in a vegetative state from which he is extremely unlikely to recover—gives you the option of refusing him further treatment for these two conditions.”

  Buddy started to say something, but Sally waved him off and asked how effective the treatment for the infection and swelling would be.

  “It’s hard to predict, but an aggressive round of antibiotics and further procedures taken to relieve cranial pressure might prolong his life.” She stood up and looked around the room. “Please talk among yourselves here as long as you want. I’ll come back this evening around seven or so, if that’s convenient for you, Mrs. Hughes?” She got a nod in return. “Sometimes it’s very helpful to talk to your pastor.”

  In the silence that followed her exit, Arthur knew that Blackwell’s implicit suggestion offered the best course of action for the family. Their father should be allowed to die. He repressed a sudden impulse to tell them about Gottlieb. He knew something about death now, something about facilitating the end of a desperate life. While he tried to shake these thoughts out of his head, Terri spoke.

  “Mom, did Dad ever talk about any of this kind of stuff? You know, like what he would want?”

  “I don’t remember him saying anything specific,” she said quietly. “From things he said watching the news, I guess he disapproved of extreme measures when there was no hope, but I don’t know if he’d want to be unplugged.”

  “We are not really talking about pulling a plug here, Mom,” she replied gently.

  “But you are talking about deliberately not treating him so that he’ll die.” Buddy stared at his family. “You’re talking about it, and it makes me sick. That’s our dad out there, and I don’t care how mangled up he is, we should be thinking about doing everything we can to save him. This is the worst thing that’s ever happened to him, and he needs all the help he can get.”

  Terri answered quietly and evenly in response to the rising inflection in Buddy’s voice. “Do you really think that Dad would want to live for months or years like a vegetable?”

  Buddy paused for a moment, sucking in a deep breath. “Of course he wouldn’t, but he wouldn’t want to be dead either.” He clenched his teeth and hissed, “I’m not going to kill my own father. That’s just murder plain and simple.”

  Sally looked stricken.

  “Do you think you could spend a little more time thinking before opening your mouth?” Terri reached over to clasp her mother’s hand. “Whatever Mom decides, we need to support her … even if we disagree with her decision. We don’t need to make things harder on her than they already are.”
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  Arthur nodded his agreement and revealed what he knew about his father’s wishes. When he had been in college, Hal’s aunt had been diagnosed with Alzheimer’s disease. Although he wasn’t close to her, he talked to Arthur at length about how much he feared losing his mind.

  “When Great-Aunt Janice got sick, he told me that if he ever got to the point where his body still worked, but his brain didn’t, someone should put him in the Chevy, point it at the Grand Canyon, and push down the accelerator.” He smiled grimly. “The thought of losing his life didn’t bother him as much as being a burden. He worried about us losing the farm. He worried about Mom being trapped. He even worried about the waste of public resources. You all remember how economical he was—”

  “Could you manage not to use the past tense?” Terri interrupted before Buddy could.

  “I’m not telling you what to do, Mom, I’m really not.” He sighed. “But I don’t think it’s wrong to ask what Dad would have wanted.”

  “You can’t have any idea what Dad would have wanted.” Buddy stood up and shouted. “I’ve worked with him every day for the last four years. I know him way better than you. I think he would want us to hope and pray and do everything we can for him.”

  He cut off Arthur’s attempt to agree with him. “You want to be totally cold-blooded and ruthless? Have you forgotten what Dad’s like? When old Bear got sick, he couldn’t even bring him to the vet’s office to have him put to sleep. Mom had to do it all by herself, so you can’t tell me he’d be on your side.” He stormed out, and Arthur shrugged at Terri. Sally looked calmer than she had before. Smoothing out sibling arguments was a familiar responsibility.

  “You need to give Buddy some time, Arthur. He’s so close to your dad. All he ever wanted to do was run the farm with him.” She brushed her hair out of her face and blew her nose. “I know that you love your father, Arthur, but you never relied on him like Buddy does. You became independent at a very young age, so you look at this a little more objectively than he can. Let me go out and talk to him.”

  “Mom, what are you going to do about Dad?”

  “I don’t know.” She kissed him gently on the forehead and left.

  When Terri and Arthur emerged from the room, the nurse told them that Mrs. Hughes and her son were in with Mr. Hughes. Only two persons were allowed to visit at a time, and the nurse was adamant about admitting visitors beyond the prescribed limit. Arthur suddenly felt claustrophobic in the waiting room and asked Terri if she wanted to grab a quick bite. Although she claimed the hospital cafeteria was adequate, he insisted they get out of the medical complex. They saw a sign for a Denny’s two blocks away and trudged to it through the dirty snow.

  “You’re right about Dad.” She waited until they were seated and had their drinks before speaking. “What you said in there, I mean. When I took the medical ethics course in dental school, he and I talked about some of the problems in the class assignments. I’m sure that he’d pull the plug on himself if he could.”

  “Why didn’t you say anything?”

  “Mom probably knows deep down what he would want, but I don’t want to push her.” She looked up at her brother. “Arthur, what if Mom’s not sure and something I say changes her mind …? I don’t want to be responsible. I’m just a coward.” She poked at her salad. “I know what he wants us to do. I just can’t bring myself to be responsible for someone else’s death.”

  “It’s easier than you think.” Arthur avoided his sister’s questioning gaze and signaled the waitress for more coffee. “What do you think Mom will do?”

  She paused. “I’m not sure, but it’d be pretty tough to deny treatment to your husband with your youngest son calling you a murderer, wouldn’t it?” Arthur nodded and changed the subject. “Are you still dating Tom Erickson?” Tom was a farmer with whom he had gone to school and whom Arthur considered to be one of the most boring people he had ever met.

  “You mean Mr. Excitement, as Buddy calls him?” Terri smiled for the first time since she left the hospital. No one in the family could keep a sour face for too long. A persistent optimism and sense of the absurd would be Hal Hughes’s two longest lasting legacies. “Things with Tom haven’t changed much. We go to the movies once a week, and he asks me to marry him once a month. Are you seeing anyone?”

  “Well, I’m sort of dating my landlady and her daughter.” He replied in as off-hand a fashion as he could manage.

  “You’re what?”

  He tried to explain how much fun he had with Suzanne and Maria. He tried to describe the charm of the old house they lived in, the seductive beauty of Clarkeston, the enigmatic and paradoxical personality of the Judge, and the intimate atmosphere Ms. Stillwater nurtured in the chambers. “You need to visit. Ms. Stillwater will fix you up with the hunky scion of a wealthy southern family in no time. You need a break from Tom and cornfields and all those patients with bad breath.”

  “I’d love to visit when things have calmed down here.” She looked at him and shook her head. “You know, it’s only been twenty-four hours since the accident.”

  “I know, Sissy.” He picked up the tab while she was in the ladies’ room, and they walked back to the hospital, shoulders hunched against the bitter wind and the situation ahead of them. As they entered the hospital, Arthur put his arm around his sister, something he never would have done before he met Suzanne. She leaned her head on his shoulder.

  When they got to the room, Terri was more comfortable with Hal than Arthur was. She walked straight to his bed and smoothed back a wisp of hair that the air vent had blown over his forehead. Arthur looked at him and realized that in every way that mattered, he was already gone. He went to the other side of the bed and rested the tips of his fingers gently on the arm that had the fewest tubes protruding from it. The body was warm, but Arthur looked at his face and still could not see his father in it. Swollen, misshapen, discolored, distorted, obscured by bandages and the respirator tube, the face belonged to no one he knew. He closed his eyes and tried to imagine his father like he had been before, but the door burst open behind him and a nurse entered with a full bag of IV solution. She replaced the bag draining into his left arm.

  “How come you’re changing a bag that’s still full?”

  “The antibiotics in the new solution are much stronger.” She hooked up the new bag and set the drip. “Your father has a fever that’s rising quite rapidly. He needs a massive dose right now.”

  “Did Dr. Perez order the change?”

  “Of course, only the supervising doctor can prescribe any kind of treatment. If you want to talk to him, I saw him with Mrs. Hughes and her son in the waiting room.” He thanked her as she left. Terri said nothing, hands supporting her chin, forehead pressed against the side of the bed. Sally Hughes had apparently come to the only decision she could live with under the circumstances; Arthur did not think that his father would be mad at her. He would not have wanted to see guilt heaped on pain.

  Terri got up slowly. “I’m going to see how Mom’s doing.”

  Arthur sat next to his father and considered his mother’s summary of their relationship. How had he become so independent over time while Buddy had just grown closer? He loved his father, and he could not think of a single man that he respected more. He shared his father’s sense of humor, his politics, and his general view of the world. Yet, he knew that if his mother had been injured, he would be bawling like a baby, while his father’s predicament left him introspective and depressed, but not devastated. It made no sense. This was a man worthy of grief. On the other hand, his father always admired a stoic.

  Unable to focus his scattered thoughts, Arthur stared at the technology that monitored and maintained his father’s vital functions. The heart monitor recorded his cardiac rhythm and provided notice of an emergency via a cable that ran from the device to the wall and then presumably to the ICU nurse’s station. No such line ran from the respirator; a respiratory emergency would go unnoticed by the ICU nurses until it adversely affe
cted the heartbeat.

  Terri entered the room. “Mom told Dr. Perez she wanted him to go ahead and treat everything, like the fever and swelling … just like we thought.” She paused for a moment. “She was willing, though, to sign a nonresuscitation order. If Dad has a heart attack or something, they won’t try to revive him. Buddy wasn’t real happy about the decision, but Mom stayed very calm. She had it all thought out.” Her voice cracked, but she managed a crooked smile. “She reminded him that Dad always let nature take its course with the animals. You never saw him giving mouth-to-mouth to a dying horse did you?”

  “Buddy didn’t push it too hard after that. Maybe he sees a difference between denying drugs and reviving a technically dead body.” She shuddered next to the technically not-dead body by her side.

  “Well, I don’t see the difference,” Arthur replied, “but I’m glad he does … Mom doesn’t need any more grief from him.”

  * * *

  Buddy sat alone, flipping through a four-month old People, lingering for a moment on the pages that displayed a little celebrity cleavage or a well-turned leg. Arthur asked him about what needed to be done on the farm in early December and who was feeding the few livestock that he and his father kept. The biggest winter jobs involved working on the heavy machinery and attending to a backlog of repairs needed on the barn and house. These chores would have to wait until his father’s condition had stabilized.

  “Will you have any problems accessing the bank accounts and credit lines and all that stuff?”

  “He put my name on everything last year, so Mom and I can handle stuff without his signature.” Buddy stopped flipping for a moment and looked up. “You know, he put my name on the deed to the farm … that still doesn’t seem right to me. You and Terri grew up there too.” He pretended to study the comparative tar and nicotine statistics on the back cover of the magazine.

  “Buddy, you know that was my idea. Dad paid a bunch of money to send me to law school and that’ll give me a steady income without having to work half as hard as you. I wouldn’t want to trade places with you. I’m too lazy. And Mom’s estate plan takes care of Terri, so you don’t need to worry about a thing except planting corn and soybeans.” He studied his exhausted brother.