Intern

by Sandeep Jauhar

  Back in the room, Anna was waiting expectantly for me, her face pale and drawn. I told her we were going to order some medicine to help her husband’s breathing. “I understand you discussed intubation with your doctor,” I said.

  “Yes, this morning,” she replied.

  “And you decided to make him DNR.”

  After a pause, she said, “What does that mean?”

  An eerie sense of calm enveloped me, like the sensation one often has before a shock. “That if he stops breathing, there will be no attempt at resuscitation,” I replied carefully.

  This time the pause lasted several seconds. “No, we never agreed to that,” she said firmly. “We want full resuscitation.”

  My breathing quickened and my heart started to pound like a drum. I asked her what they had discussed with their doctor. I didn’t know if she had misinterpreted the conversation or if she was now changing her mind.

  “We talked about what to do if he becomes a vegetable. But we want to do everything possible right now. Right, Armen?” It was not so much a question as a tragic, plaintive demand.

  Izanian’s face had turned a sort of reddish blue, the color of a hematoma, a sign of profound hypoxia. “We had—” he said, pausing for breath, “a discussion—we agreed—to—DNR—but then—we changed—our mind.”

  I sprinted to the nursing station, where Feldman was leafing through the chart of a different patient. He told me he had written the order for the antibiotic.

  “I’m calling the ICU,” I said, grabbing a phone.

  “Why?” Feldman cried. “I told you, he’s DNR!”

  “No he’s not!” I shouted. “His wife said they want a full code.” A couple of nurses looked up from their late night snacks.

  For the first time that night, Feldman appeared fazed. “They—they can’t do that,” he stammered.

  “They just did,” I snapped. I swiped Izanian’s chart off the rack. In the front was a DNR form. Scribbled on it was an attending physician’s signature but not Izanian’s or his wife’s. “Look,” I hollered, rapping my knuckles on the sheet. “They didn’t even sign the form. They agreed to something, but it wasn’t DNR.”

  Feldman dropped what he was doing and ran to get an arterial blood gas (ABG) kit. Maricel Gomez, the critical care fellow, was surely going to require an ABG before accepting Izanian to the ICU. I called her in the unit and quickly summarized the case. I told her about the metastatic cancer and the fevers that had brought him to the hospital. “Something obviously got mixed up with the DNR,” I said breathlessly. “I guess the family didn’t realize what they were agreeing to. Right now he is tachypneic, breathing thirty-five times a minute on positive-pressure ventilation. His oxygen saturation is about ninety percent. We’re drawing a blood gas, but I think he’s getting tired, and I wanted to let you know sooner rather than—”

  Gomez cut me off before I could finish. “I can tell you that he is not a candidate for the ICU,” she declared in a thick Filipino accent.

  I started to speak but froze in mid-sentence. Had she not heard me? “He is not DNR,” I repeated.

  “It does not matter,” she replied calmly. “In a cancer hospital, everyone could end up in the ICU. But we have to make choices.”

  I had never heard of a patient being rejected by the ICU because he was too sick. “So what do you want me to do?” I stammered. “The family wants everything done.”

  “You should try to make him DNR.”

  “They don’t want it!”

  “Then you can intubate him on the floor. But there are no ICU beds for this patient. He will not benefit from ICU care.”

  I couldn’t believe how cavalierly she was dismissing him. “Are you going to write this in the chart?” I demanded. The medico-legal threat worked sometimes, but not this time. “Of course,” she replied.

  “Can you at least come see him?” I pleaded. I had never intubated anyone on my own.

  “I’ll come by and take a look,” she said. “But it will not change my decision.”

  She soon appeared at the nursing station, a stocky Filipino woman carrying an array of beepers on the waistband of her tight gray scrubs. Without acknowledging me, she sat down with Izanian’s chart. After a couple of minutes, she told me to take her to him.

  In the room, she bore down on Izanian, who was now gasping for breath. She started off by reviewing his medical history as Feldman and I stood stiffly behind her. Though her tone was icy and monotone, I was impressed by how quickly and accurately she had digested the complicated chart.

  “If we put in a breathing tube, there are two courses,” she explained to Anna. “If it is the cancer that is making him like this, he will not get better. The breathing tube will not make the cancer go away, of course. If it is pneumonia, then the tube may help—but when we take it out, he still has cancer.” She made the last comment with a rhetorical flourish, like a debater who has just made a clever point. Izanian and his wife stared at her, saying nothing. Feldman looked away, appearing bored.

  Gomez repeated the options, describing a decision tree where all paths lead to the same outcome. “We can intubate him if you wish,” she said to Anna. “But he will have to stay on the floor. There are no ICU beds available.”

  Like June Steinway’s daughters, Anna seemed paralyzed by the choice before her. “What do you recommend?” she asked softly.

  “I cannot tell you what to do,” Gomez replied sharply. “But I can tell you that not everyone gets a breathing tube. When my father died, he did not have intubation.”

  “How long would the tube have to stay in?” Anna asked.

  “I cannot say,” Gomez replied impatiently. “It all depends on what is making him like this. If it is pneumonia, maybe a few days. If it is cancer . . .” Her voice trailed off.

  Anna patted her husband’s cheek. He opened his eyes. “What should we do, Armen? Should we try the breathing tube?” Behind the mask he scowled, appearing lethargic and confused, probably due to a lack of oxygen. Anna turned back to the fellow. “We want to do everything possible—”

  “Then we have to intubate him now,” Gomez interrupted.

  “But could we wait a little longer to see if he gets better on his own?”

  “No!” Gomez barked. “Now is the emergency, now is the time. We do not want to intubate him in the middle of a respiratory collapse.”

  Anna looked at me helplessly. My vision momentarily clouded as tears filled my eyes. The death of a spouse is hard enough to accept without having to sanction it in the middle of the night. I thought once again of Lisa. What if we had gotten married? What if I were the one standing in Anna’s shoes right now? Medicine, I was beginning to learn, is about life. In the struggles of your patients, you can find yourself.

  “You can sign the DNR form now,” I whispered, trying to break the impasse. “We can intubate him later if you change your mind.”

  Gomez spun around and glared at me, as if I had committed the worst mistake. Then she turned back to Anna. “Once you sign the form, we will not intubate him,” she said.

  “And we cannot decide for intubation later?” Anna asked.

  “No,” Gomez replied firmly. “If we are going to intubate, we must do it now. So what do you want to do?”

  Anna did not say anything.

  “Are you prepared to sign the DNR?”

  Anna nodded, blinking away tears. “We can try calling the attending,” I offered, receiving another icy look.

  “Yes, okay,” Anna said, appearing relieved. “I would like to speak with him.”

  “So do I understand you correctly?” Gomez said threateningly. “You do not want us to intubate him at this moment? You want to wait to speak to the attending?”

  Anna nodded, trembling.

  “And what about CPR? What if he has a cardiopulmonary arrest before we can reach the attending?”

  “CPR is okay,” Anna said. “Just no intubation right now.”

  “You can’t say yes to CPR and no to intu
bation,” Feldman blurted out. “That makes no sense.”

  Gomez ordered us to step outside.

  “Basically they want us to intubate him when he codes,” Feldman said mockingly in the hallway.

  “That’s their right,” I said quietly.

  “But they have incomplete information!” Feldman cried. “They don’t know what it means to say no to intubation and yes to CPR. The first thing we’re going to have to do in a code is secure his airway. A, B, C,” he said, condescendingly raising three fingers. “Airway, Breathing, Circulation.”

  “It’s still her decision,” I said, hating the ill-mannered punk. “Whether it is right or wrong.”

  Gomez put up her hand, signaling an end to the discussion. Her expression toward me had turned from contempt to pity, as though she thought me pathetically naive. “I’m going to call the attending,” she announced quietly.

  The attending physician on call that night had never met Izanian or his wife. Back in the room, we struggled to put the phone to Izanian’s ear, but the oxygen mask kept getting in the way, and the noise from it made it impossible for Izanian to hear or be heard. When the mask was removed, his blood oxygen saturation started to plummet. After multiple attempts, Gomez finally passed the phone to Anna. She listened for a few seconds. “Yes,” Anna finally said into the receiver. “We want to fight. We have no choice but to fight.”

  Gomez bolted out of the room to get an intubation tray. Feldman went to answer a page. Finally we were alone.

  Medicine is a stochastic science—no doctor can predict the future—but in this case the outcome was never in doubt. Advanced cancer patients who end up on ventilators die during their hospitalizations. Life support was futile, and the idea of inserting catheters and tubes into this man seemed inhumane. Even though I despised Gomez’s approach, I knew she was right. DNR was the only acceptable choice in this case. A breathing tube was going to mean a lot of suffering without any realistic possibility of gain.

  Fatigue was setting in. In the dim dawn light, Anna asked me what to do, and I told her.

  The next morning, I stopped by the room. The priest had left; Izanian’s body had been moved to the morgue. Anna was still sitting at the bedside. Her hair was mussed, her jewelry askew. She had on the same outfit as when I had met her two days ago. I sat down and told her that I was sorry.

  “He was supposed to be my friend for life,” she said softly. “I wish I could have done something for him.”

  “You did a lot,” I said.

  “But did I do the right thing?”

  I had asked myself that same question. “Putting him on a ventilator would have prolonged his suffering,” I said.

  She nodded, blinking away tears. She noticed my wedding ring. “You are married?” she asked.

  I nodded.

  “Live each moment like it is your first,” she said. “Sometimes it is hard, but you have to try.”

  OVER THE YEARS, I have come to appreciate how problematic informed consent can be, and not just in emergencies. When I started residency, I viewed patient autonomy as an absolute good, an ethical imperative that trumped all others. In medical school I had learned about some of the infamous breaches of autonomy in the history of medicine: the Tuskegee study in the 1940s in which black men with syphilis were intentionally left untreated, despite the availability of penicillin, in order to study that disease’s complications; or the Willow-brook study where developmentally disabled patients were intentionally infected with hepatitis. Even today, patients continue to be enrolled in experimental drug studies without proper consent, or under tacit intimidation.

  Informed consent was supposed to guard against such abuses. But informed consent is practiced very differently from the way ethicists envisioned it. It was supposed to protect patients from doctors. Instead it is used to protect doctors from patients or, rather, from the hard decisions that patient care demands. Doctors nowadays sometimes use informed consent as a crutch to abdicate responsibility.

  A few years later, when I was a cardiology fellow, a patient of mine had an angiogram. He was still lying on the operating table, catheters in his groin. A cardiologist called me over to review the film.

  When I got to the cardiac catheterization lab, two attending physicians and a senior fellow were studying the angiogram on a computer monitor. The coronary arteries were sectioned off by five narrow blockages.

  What to do? The senior physician favored angioplasty. Two blockages could be opened today, he said, and three at a later date. The others thought bypass surgery was the better option. Someone asked my opinion.

  I thought about it for a few minutes. Surgery was probably the more durable solution. Bypass grafts could last a decade or more, longer than most stents. Plus, surgery for my patient meant one procedure, not two.

  Still, there were risks. Because of his advanced disease, my patient probably had about a 10 percent chance of dying in surgery. If he survived, he could be left with memory deficits or chronic chest-wall pain. Plus, it would take longer for him to recover from surgery.

  Since we couldn’t reach a consensus and it wasn’t an emergency, the senior attending physician made what seemed like a reasonable proposition: give the patient the options and let him decide. After all, he was the one who was going to have to live with the consequences.

  He was lying on a long, narrow table, a middle-aged man covered from neck to toe by a sterile drape. His face had a strangely disconnected look, which I attributed to anxiety and sedation. He smiled as I approached. “The angiogram is done,” I started off saying.

  I told him he had five blockages in three arteries and two options. Angioplasty could open the arteries without surgery, but he would need two procedures, one of which could be started right away. Open-heart surgery, on the other hand, probably offered him the best chance of not having to undergo another procedure in the future. “But it’s a big surgery,” I added.

  I didn’t want to bias him one way or the other. A few months before, I had convinced a patient to have heart-valve replacement surgery, which had resulted in serious complications. I didn’t want another bad outcome on my conscience.

  He listened intently but did not say much. I repeated his options. He nodded. So what did he want to do? He looked puzzled. “What is best?” he replied.

  That I was having this conversation at all is testament to how much medicine has changed in the last two or three decades. In hospitals today, “patient autonomy” is the ruling ethical mantra, even superseding beneficence. But it can be a problem.

  For one thing, patient autonomy often seems to be more important to doctors than patients. Sometimes patients want to hear their options and make their own decisions, but just as often, in my experience, they want doctors to guide them through the tough decisions and, yes, sometimes, tell them what to do. The father of a friend of mine died a few years ago from lung cancer. My friend told me that when he asked the doctors about chemotherapy, they gave him numbers and statistics but assiduously avoided giving advice, which was what he really needed.

  “What is best?” my patient asked me again. “I can’t tell you what to do,” I repeated. He stared blankly at me. I shifted my weight, feeling frustrated. Then I decided to start acting like a doctor.

  “What are you afraid of?” I asked. It turns out his uncle had had open-heart surgery a few years back. Judging by his tone, he wanted no part of it. “It sounds like you’re scared of surgery,” I said. He nodded. “So we should do the other thing,” I said. The patient agreed, so we did an angioplasty. It went well.

  Another issue I continue to struggle with today is how to balance patient autonomy with the physician’s obligation to do the best for his patient. As a doctor, when do you let your patient make a bad decision? When, if ever, do you draw the line? What if a decision could cost your patient’s life? How hard do you push him to change his mind? At the same time, it is his life. Who are you to tell him how to live it?

  In my second year of residency,
I took care of a gay man who had a CT scan of his head because of weakness in his legs and difficulty concentrating. It showed signs of a brain infection often associated with AIDS. I advised the man to have an HIV test. “If you are infected,” I told him, “it is better to know early.” But my patient refused. He said he didn’t believe that HIV caused AIDS. When I pressed him, he emphatically stated he didn’t want to discuss the matter any further.

  My patient was neither psychotic nor delusional. For the most part, he spoke calmly and rationally. I didn’t want to force him to take a test he didn’t want, yet I didn’t want his disease to progress to the point that it would be untreatable. I wasn’t sure what to do, so I did what most doctors do in these situations: I called a psychiatrist.

  The consulting psychiatrist that morning was a tall man with a serious, deliberative style befitting his line of work. I spoke with him in the hallway after he evaluated my patient. “Clearly he’s making a bad decision,” the psychiatrist said. “But that isn’t enough to deem him incompetent.” My patient’s thoughts were not grossly disorganized, and he wasn’t obviously depressed or psychotic. “He is showing impaired judgment,” the psychiatrist went on. “But we all have impaired judgment from time to time.” In other words, my patient could make a bad decision if he wanted to.

  I felt torn. How far should a doctor go to make a patient do the right thing? When do the demands of beneficence outweigh those of patient autonomy? First, do no harm, I had been taught, but what about the harm a patient can inflict on himself?

  Medical decisions necessarily involve value judgments, and who better to make those judgments than the patients involved? If a fashion model doesn’t want surgery because it will leave a scar on her face, it may make sense in the context of her value system. Even though I may not agree with her, I can understand her reasoning and abide by her decision.