Hospital

by Julie Salamon

  A few hours after the Ms. Hernandez discussion, I accompanied Lisa Keen to a patient’s room where a Chinese man in his fifties lay dead on his hospital bed. He had died unexpectedly that morning during an operation in which a Greenfield filter was inserted into a vein. Keen said she didn’t know what caused the death—a blood clot, a heart attack, or the procedure itself.

  Keen had talked the nurses into keeping him out of the morgue until one of his children could drive to Brooklyn from college in upstate New York, which would take several hours. The man’s daughter held his hand while his wife wept. In the hysterical sadness of the room, only the dead man appeared calm. Keen told the daughter she was looking for a Mandarin interpreter to talk to her mother, who didn’t speak English.

  When we returned to the social-work office, two women in their forties wearing hospital badges were working the phones, weeping. I was touched at their empathy for the dead Chinese man until I learned they were weeping for themselves. They were surgical physician assistants who had been laid off because of the budget cuts. They introduced themselves as Josephine and Lisa.

  Josephine was saying, “Feldman has done nothing but fuck up everything since he’s been there.”

  Lisa said, “They didn’t even call to say good job. Nothing.”

  Josephine chimed in. “It should have been done differently. It should have come from Cunningham, not from the administrator. He brought me in. We’ve been here ten years and twenty years. I would not have expected the man to do it this way.”

  Death shouldn’t come as a surprise, certainly not in a hospital, definitely not when its imminence is a foregone conclusion. Yet a week earlier, on January 23, when I arrived at the cafeteria’s back room for Monday-morning biopsychosocial rounds and no one was there, I was shocked to hear the messageI found on my cell phone. Alan Astrow called to let me know Sharon Kopel had died Sunday, yesterday, the funeral was today at one, and biopsychosocial was canceled.

  It was a gloomy morning drenched in rain. I decided to walk the twenty blocks to the cancer center, figuring I could catch a ride to the funeral. Feeling chilled and empty, but not ready to talk to anyone just then, I factored in a stop at a Chinese bakery for tea and the comfort of solitude among strangers. On the sidewalk outside the Eisenstadt building, trying to open my umbrella, I bumped into a man wearing a black leather jacket. It was Steve Davidson, the ER chief. We exchanged awkward mumblings of sorrow, and he told me he had practically lived at the Kopels’ his first seven years at Maimonides, when his family remained in Philadelphia and he commuted.

  Davidson said that Sharon fed him physically and emotionally during those years. He said she had come back from the brink of death many times in the past two years, since September 2003, the date of diagnosis. He said Sam, like anybody, was devastated at the loss but also relieved that the ordeal was over.

  The words stopped. Time stopped. Rain fell around us, but we were dry beneath the underpass connecting Gellman and Eisenstadt, neither strangers nor friends, bound and separated by our very different relationships to Sharon Kopel, our professional concerns vis-à-vis one another, our private thoughts of death. I had spent many hours talking to Davidson, learning about his past and his travails with Hatzolah, connecting his impressive mass of charts and data with the mob scene in his emergency room. We had gossiped, joked, and philosophized. I had become enmeshed in his world, but I was also suspect, witness, and judge, always watching and recording. Even in this instant of suspended reality, hyperaware of the collective sorrow unleashed by one death, intellect swamped by feeling, we were walled in by our own mass of data—not unlike the relationship of doctor and patient, or patient’s family, it occurred to me later.

  He reached toward me and patted me on the arm—a clumsy, doctorly pat. We turned in separate directions into the windy spray, he toward the ER, I toward Chinatown. On Eighth Avenue, I walked past the big church that advertised services in English and Chinese, past hair salons and grocery stores, past the man selling hot noodles with sauce from a cart covered by plastic. A thicket of umbrellas turned the sidewalk into a maze. I angled mine to squeeze through. A few blocks from the cancer center, I took refuge in a crowded bakery, sitting knee to knee with other damp people, almost all Asian. As they stared at the television showing news in Chinese, I watched a man scratch a Lotto ticket and then throw it on the floor. I drank hot tea from a Styrofoam cup, sweet milky solace for seventy cents, blissfully unable to understand a word being spoken around me.

  I thought about Alan Astrow’s spirituality conference in November. Chun-fang Yu, the Columbia professor who specialized in the effect of Buddhist thought on Chinese society, had invoked the concept of the “good death.” Yu’s subject was not mercy killing, not euthanasia, another kind of good death, derived from the Greek words for “good” (eu) and “death” (thanatos). There the object was to help a dying person escape suffering through active intervention, the actual termination of life. Yu described “the good death” as a state of being similar to the final stage of acceptance postulated by Elisabeth Kübler-Ross in her classic treatise On Death and Dying. For Yu the good death meant “being at peace with oneself,” of facing death without fear.

  The professor, a solid woman of about seventy, with close-cropped hair, spoke in a heavy accent with a reassuring blend of humbleness and authority. She said her own parents, who had remained in China, both died of colon cancer and were never informed of their illness or prognosis. “Not knowing makes it hard to prepare,” she said. “Buddhism says we are one. We are interconnected, and we suffer when we feel there is a separate self. If you see only a cloud, you are very sad. You forget the cloud becomes rain. But many, many Buddhists are not ready. Many people are not capable of dying a good death.”

  After Professor Yu spoke, a psychiatrist discussed hope and paraphrased Václav Havel, the absurdist writer who became a political activist and then the last president of Czechoslovakia and first president of the Czech Republic. Later I looked up the quote in Disturbing the Peace, a collection of essays by Havel, including the pertinent one called “The Politics of Hope.”

  “Hope is definitely not the same as optimism,” wrote Havel. “It’s not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out. . . . It is also hope, above all, which gives us strength to live and to continually try new things, even in conditions that seem as hopeless as ours do, here and now.”

  I thought about meeting Sharon Kopel, three months earlier, on a gray October afternoon, in the Kopels’ rambling, comfortable Victorian house, fifteen minutes by car from the hospital. They lived in Prospect Park South, an idyllic, leafy enclave in Flatbush, conceived at the turn of the twentieth century by Dean Alvord, a visionary real-estate developer. Describing the community as rus in urbe, or “the country in the city,” the real-estate man wanted to leave his mark on the present and the future, with houses of architectural distinction and a landscape that reflected the cycle of life. “Alternating every 20 feet were Norway maples, for permanence, and Carolina poplars, for immediate shade,” explains the American Institute of Architects’ AIA Guide to New York City. “The short-lived poplars, Alvord and his architect, John Petit, reasoned, would die out as the maples reached maturity.”

  The maples had grown large; the poplars were gone. Sharon Kopel was wasting away. Her emaciated body barely made a ripple on the overstuffed chair where she rested and watched television, mainly cooking shows. She was an accomplished cook. The chemotherapy made her too sick to eat much, but she could dream. Sam greeted me and gave me a quick tour of the house. That’s when I saw the piano he’d traded up for from the one given to him by his former partners, now the antagonistic Bashevkin group. I saw toys belonging to the Kopels’ two young grandsons. I had seen Sam only at work, aloof, dressed in a white doctor’s coat or jacket and tie. Now I saw him as the patient’s husband, wearing jeans and a look I interpreted as heartbreak. He brought Sharon a nice snack
of focaccia with mozzarella cheese, tomato, and olive oil—a lunch she barely touched—and left us alone to talk.

  Her voice was thin and quavery. Her breath was short. Occasionally she apologized for forgetting certain words—a side effect of the chemo, she explained. Though she insisted that she was in denial, she discussed her diagnosis and treatment—and the history of the cancer center, including the feud with the Bashevkin group—with fierce and funny Brooklyn articulation.

  “It’s about two years right now since I started chemo,” she said. “I found out about the cancer and started the chemo all in the same week, not a luxury most people have. You can sometimes wait two weeks for an appointment and another two weeks for the test results; you may have to go to Manhattan or the Bronx, and by that time you might as well be dead you’re so aggravated.”

  I remembered Sam’s description of her. “Fierce,” he said. “‘Fierce’ is a good word. A really good word. Fierce and uncompromising. I would say unforgiving, but that’s too harsh. She could forgive. But she was a tiger in defending me.”

  Maybe that explained why she had been willing to talk to me, despite the obvious effort it cost her. Even then, shrunk by half from her heaviest self, when she tipped the scales at 182 pounds, she was watching out for Sam, as she always did. “On top of everything else, Sam is having to take me around, taking care,” she said. “I’m in denial most of the time. I don’t think about it. I watch television and just pretend. I can’t even think what this has done to him.”

  The cancer center had led me to Maimonides. Like the feuds at the hospital, Sharon Kopel’s illness was built into the cancer center’s core, as surely as the steel and cement that encased Jay Cooper’s linear-accelerator radiation machines. Remember, Sam’s interest in building the center a decade earlier became obsessive only after his wife’s first round of cancer, when he was awakened to just how unpleasant the hospital’s radiation facilities were. She encouraged him as his first and second and third efforts fell apart. She kept the grudge with his former partners alive; nothing that hurt Sam could be overlooked. Then she volunteered to help with an organization collecting smoking data for a cancer project. There she met Steven Cymbrowitz, the Brooklyn assemblyman whose wife had recently died of cancer. Sharon told the assemblyman about Sam’s many failed attempts to start a cancer center at Maimonides. Cymbrowitz met Sam and came on board with the promise of some public money at a time when the hospital was ready to make the commitment. The groundbreaking ceremony to announce the beginning of construction was set for September 25, 2003.

  For almost a year before that, Sharon experienced a steady barrage of swarming pain in her lower back and abdomen. The sensation resembled powerful menstrual cramps, but she had already gone through menopause. She said she was annoyed because she was unable to help her daughter, who had just given birth to her second child, as much as she had hoped. Sharon said she wasn’t alarmed. Illness had been part of her life since she was a teenager and learned she was diabetic. Her adult life had been punctuated by periods of sickness, often related to complications from the diabetes, which damaged her eyes and almost destroyed her feet. In addition there were angioplasties for cardiac damage and a long history of back pain, including one bout, when she turned fifty, so severe that she couldn’t walk for weeks.

  She didn’t ignore the pain. “I’m very diligent about going to the doctor,” she told me. Her mother had died of a rare form of cancer that had eluded doctor after doctor, test after test. Sharon was careful. For her back pain, she went to her chiropractor and physical therapist. Sam arranged for a pelvic sonogram, which was followed a few months later by a CAT scan. The pain widened from her back to her right side to her left side. A neurologist examined her, and a pain specialist told her she had a pinched nerve. The painkillers he gave her helped for a while, but by the summer of 2003, she was miserable again.

  They didn’t go to the Berkshires that summer. Sam was consumed with the cancer center, working seven days a week. Sharon was consumed with pain. Over Labor Day weekend in September, they finally went to the country, where Sharon spent the weekend lying on the couch. Back in the city, more trouble: Sam’s mother, suffering from Parkinson’s and dementia, was taken to the hospital; though a Do Not Resuscitate order was prominently displayed on her refrigerator, she had been intubated and died in a coma a few days later.

  The following week, after the Kopels observed shivah, the seven-day mourning period, Sharon had another MRI for her spine. She had postponed the test for a week because of her mother-in-law’s death.

  That night after dinner, Sharon said, Sam told her she had to go for another test the next day, and she said she couldn’t, she had a dentist’s appointment. He was insistent, she recalled. “You’re not going to the dentist, you’re going to drink this stuff,” referring to the barium solution, which she described as “banana-tasting chalk.” She told this story with a wistful look of amusement, as though recalling a romantic moment rather than the prelude to her death sentence.

  “Which goes to show I did teach him something,” she said. “No bad news before dinner is over.”

  The next morning she recalled taking a change of clothes, because after the test she and Sam were going straight to the groundbreaking ceremony. “You don’t want to look like you’ve been to the doctor,” said Sharon.

  She recalled Sam saying, “You have ovarian cancer,” and her asking, “How? They looked behind every nook, every corner, every cranny—how?”

  She didn’t remember much after that, except that she did change clothes and went with Sam to the celebration of his triumph—their triumph.

  Pam Brier told me that the instant she saw the Kopels arrive at the groundbreaking ceremony, she knew that something was wrong. “I could just tell by the looks on their faces that things were not good,” she said. “I remember looking at Sam and Sharon and thinking, ‘Maybe they had a fight.’ They just did not look good, and they definitely came in later than other people.”

  Brier always had sensitive radar for the placement of people and things, but her antennae were particularly alert that day, less than three months after the accident that had almost killed her and her husband. Peter was still in the hospital, and she had just come back to work. This was her first public appearance, and she was determined to give the impression that she was in control of the hospital. She left her wheelchair in the car, out of sight of the gathered local officials and hospital personnel, and used a walker to make her entrance.

  “I was really focused on trying to move one foot in front of the other and get through the thing, because it was really hard,” she recalled.

  Later, after she learned why they looked stricken, a thought occurred to her, a thought that stayed with her throughout her recovery and that revealed much about Brier’s intricate psychology. “It was like you look at two planes intersecting in the air, and you see that for one the trajectory goes one way and for the other, something else,” she said. “I thought, ‘Here you are, Pam, and your trajectory is so positive, and Sharon’s is so negative. Listening to accounts of Sharon getting sicker and sicker was so significant to me—aside from the irony of the whole thing, and the tragedy of the whole thing—she was the person I kept in mind as I got better and better. As I got strong and stronger and more and more back in the world, I stopped thinking about it so much. But in those first months, that first year, you can believe she was in my mind as the possible other course.”

  In 1961, 90 percent of the doctors responding to a survey by the Journal of the American Medical Association said they would not tell their patients they had cancer. By 1979 almost all the physicians responding to a similar survey (97 percent) said yes, they would tell their patients. In 1977, reflecting on this sea change in attitudes, an oncologist named Franz J. Ingelfinger delivered a lecture at the Harvard Medical School shortly before he retired as editor of the New England Journal of Medicine. In that lecture he defended the physician’s right to treat patients with “authoritar
ianism, paternalism and domination.”

  Ingelfinger used his own experience as a cancer patient to support his position. After he was diagnosed with a glandular cancer, which was removed surgically, he faced the decision of whether to receive prophylactic chemotherapy and/or radiation therapy. His surgeon saw no visible evidence that the cancer had spread, but it was possible that it had. Both chemotherapy and radiation therapy could produce debilitating side effects. The physician /patient was bombarded with well-meaning, contradictory advice, all of which made him more indecisive. One day a friend told him, “What you need is a doctor.”

  “He was telling me to forget the information I was receiving from many quarters,” said Ingelfinger, “and to seek instead a person who would dominate, who would tell me what to do, who would in a paternalistic manner assume responsibility for my care.”

  Ingelfinger followed his friend’s advice. “My family and I sensed immediate and immense relief,” he said. “The incapacity of enervating worry was dispelled.” Ingelfinger recognized that paternalism was a form of arrogance and that “a physician can be beneficially arrogant, or he can be destructively arrogant.” He defined destructive arrogance as “accentuated by insolence, vanity, arbitrariness . . . lack of empathy.”

  The New England Journal of Medicine published Ingelfinger’s lecture as an article called “Arrogance” in December 1980, eight months after the author’s death. Sam Kopel sent me a copy when I asked him what his philosophy of medicine was. “I can’t say I have a philosophy,” he told me, “but the way I practice has been heavily influenced by something I read twenty-odd years ago. You must present the options as honestly, fairly, and effectively as you can, and you have to frankly admit to what you don’t know. But you can’t dodge the responsibility for making a recommendation.”