Intern

by Sandeep Jauhar

  The problem with my gay patient was that I couldn’t understand his reasoning. It seemed arbitrary to me, borne out of flawed reasoning and misinformation, not careful logic. It was the wrong decision for the wrong reasons, but by the ethics prevailing in medicine, I couldn’t force him to make a better one. Even so, hardly a week goes by that I do not wonder if I should have tried harder to persuade him to have the test.

  Over time, my views on informed consent have evolved. I no longer view paternalism as suspiciously as I once did. I now believe that it can be a core component of good medical care.

  Not long ago, as an attending physician in the CCU at the hospital where I now work on Long Island, I got an early morning call from a cardiology fellow. Mr. Smith could not breathe. Bright red blood, filling up the air spaces in his lungs, was spewing from his mouth whenever he coughed.

  “So what are you waiting for?” I asked the cardiology fellow on the phone, trying to rub the sleep out of my eyes. “Intubate him.”

  “He says he doesn’t want a breathing tube,” the fellow replied.

  “He’s going to die without it,” I hollered.

  “I know,” the fellow said matter-of-factly. “And I think he knows, too. But he still doesn’t want it.”

  I sank onto my living room sofa. What to do? Mr. Smith had come so far since his heart attack. Cardiac catheterization. A drug-coated stent to open up a blocked coronary artery. Intravenous blood thinners to keep the stent from clotting. Was it going to end like this?

  “This is a reversible complication,” I told the fellow. I had seen such bleeding before with aggressive blood thinning. With a few days of ventilatory support, the bleeding should stop, we would be able to pull out the tube, and he would walk out of the hospital.

  “What do you want me to do?” the fellow replied. “He’s refusing.” He said that he had already tried the usual measures short of intubation: supplemental oxygen, diuretics, a pressurized face mask.

  “Do you think he has decision-making capacity?” I asked. If not, we could make the decision for him.

  “I think so,” the fellow replied, his voice thick from lack of sleep. “He apparently told the residents several days ago that he never wanted to be intubated.”

  “He can’t do this to himself,” I said. “Try to talk to him again. I’m coming in.”

  Outside, the sun was rising. Speeding to the hospital on a lonely stretch of highway, I mulled over the options. As far as I could tell, there were only two: we could continue the current treatments and watch him die; or we could intubate him against his wishes.

  From my car I called my brother, who had performed the catheterization. “Intubate him,” Rajiv said immediately. I explained that Mr. Smith did not want a breathing tube. “Who cares?” he cried. “He’s going to die! He’s not thinking straight.”

  Perhaps Rajiv is right, I thought. After all, who in his right mind wants to die? Were we not asking too much of Mr. Smith? In an emergency like this, how could we expect him to make the right choice, any more than the cardiology fellow could have expected June Steinway or I could have expected Anna Izanian to do so years ago? As an experienced cardiologist, wasn’t I in a better position to make Mr. Smith’s decision than Mr. Smith?

  When I got to the cardiac care unit, a crowd of doctors and nurses was at the patient’s bedside and an anesthesiologist was preparing to insert a breathing tube. My brother took me aside. “He was breathing at forty times a minute and his oxygen saturation was dropping, so I made the decision to intubate him.”

  I nodded quietly. I had made the same decision in the car.

  Once the breathing tube was in, blood started rising in it like a red column. Nurses had to scramble for face shields and yellow gowns to protect themselves from the red spray. Pretty soon someone was pouring brown antiseptic soap onto Mr. Smith’s groin in preparation for a central intravenous line. As needles started piercing his skin, Mr. Smith started swinging wildly. In intensive care units, the steamroller of technology starts moving quickly, flattening all ambivalence.

  Eventually, with sedation, Mr. Smith settled down, and the critical care unit staff settled in for a long period of observation. If we had gambled right, he would recover within a few days. “If you get through this,” I whispered to Mr. Smith, “I hope you can forgive me.”

  Mr. Smith had a rocky hospital course. The bleeding in his lungs continued for several days, requiring large blood transfusions, but it eventually stopped. His blood pressure was too low, then too high. He had protracted, unexplained fevers.

  After a few days, I rotated off service as the attending physician in the CCU. Over the following week, Mr. Smith remained intubated. A week later, I heard that his condition had improved. A week after that, a fellow stopped me in the hall to tell me that the breathing tube was out.

  When I went to see him, I realized that I had never really looked at him as a person. He was a tall, muscular man in late middle age, with a broad forehead, a flat nose, and high, handsome cheekbones. I went to his bedside and introduced myself. He didn’t recognize me.

  “When you were really sick, I was one of the doctors who made the decision to put in the breathing tube,” I said. He nodded, eyeing me curiously. “I know you didn’t want the tube,” I went on, “but if we didn’t put it in, you would have died.”

  He nodded again. “I’ve been through a lot,” he finally said, his voice still hoarse from two weeks of intubation.

  “I know,” I replied.

  “But thank you,” he said.

  Some months later, I was asked to attend a meeting of the ethics committee at my hospital, of which I am a member, to discuss my actions. On the committee were nurses, social workers, physicians, and a rabbi wearing a yarmulke who often quoted the Talmud. My hands were clammy as I walked into the room that morning, mulling over how I was going to respond to their questions. When my case came up, I told the group I had decided to intubate Mr. Smith because I was not convinced that the CCU house staff had had the proper discussion with him before making him DNR. Not having had the conversation myself, not knowing whether he had been properly informed of his choices or truly informed when he made his decision, I decided to err on the side of preserving his life. “I feel at peace with myself,” I said. “I feel justified that I made the right decision.”

  A discussion ensued about the nature of paternalism. The head of the committee, a graying, grandfatherly man, explained that paternalism derives from the image of the paternal figure, the father, in a family. The father is motivated by an interest in his children’s welfare. He acts on their behalf, but not at their behest. The beneficiaries—his children—may even repudiate the actions taken on their behalf. “Are we saying that as doctors we can reject patients’ preferences by saying that their directives do not apply to their current circumstances or by saying they lack capacity because it is an emergent situation?” he asked. “Are we saying that as doctors we are all-knowing and that we have the last word?”

  He wrote “patient > doctor” on a large sheet of paper. Autonomy trumps everything, he said, if the patient has capacity, but who decides? “The doctor, of course,” he answered, “so ultimately the patient can decide only if the doctor says so.” In the end, he said, the power structure in medicine is such that only doctors can decide whether patients have the right to exert their autonomy. And how do doctors decide? “Well,” he said, “it’s based on their experience, their prejudgment, their prejudice; and some doctors have the prejudice that patients cannot make medical decisions for themselves. So in these cases, paternalism rules, and it’s a slippery slope toward a situation where autonomy is always undermined.”

  “All too often,” he added, “when we judge that what the patient wants is reasonable, we decide the patient has capacity. That means we ultimately decide that they should be respected only when we agree with them.” The words of Dr. Klein rang through my mind: “We can get them to do whatever we want. As long as they agree with us, they’re no
t crazy.”

  A doctor with spiky gray hair said he agreed with me about intubating Mr. Smith. “I respect my patients, their choices, what they tell me,” he said. “But it can’t be black or white. I would have done the exact same thing as you did. It’s about informed consent. If you are not comfortable it was done properly, I too would have erred on the side of intubation.”

  A social worker said: “My mother had been on a ventilator. The resident came by to talk to her, asking if she ever wanted to be on a ventilator again. It was like he was trying to finish another task, like he was checking off a box. There was no substantive discussion. I applaud you for doing the right thing. I think your behavior was perfectly ethical.”

  An ER physician said that patients were often brought in with life-threatening conditions. “One young woman said she didn’t want to be intubated. I intubated her anyway. When her family came in, we talked about it, and they were thankful. And when she woke up, she was obviously happy that she didn’t die.”

  In response, the head of the committee said it was important to distinguish hard from soft paternalism. Hard paternalism, he explained, was when physicians did not believe that patients have the capacity to understand the decisions before them. “You think, ‘They will better understand when they think like me.’ Like with children when you say to them, ‘Why do you have to do this? Because I say so.’ As a parent, you are duty-bound to prevent your kids from making bad decisions or doing harm to their bodies. Soft paternalism is different. Here you aren’t sure if the patient understands. In soft paternalism, you have negotiations. You try to persuade the patient to see things from your viewpoint.

  “For Mr. Smith, I might even advocate a position of hard paternalism. The standard for decisional capacity goes up the more severe the consequences of the decision. For the trivial decisions, we don’t demand such a high standard. ‘Oh, the patient refuses an IV? Okay, fine.’ But here the consequences were catastrophic, and fortunately there was a good outcome.”

  He shuffled his papers together. “I feel compelled to have the last word. We want to be careful about saying patients can never make the right decisions or cannot give informed consent because their past directive is no longer applicable. We run the risk of saying, ‘Patients have to listen to us. We are the first and last authority.’ There is always a danger that doctors decide that they know better.

  “But in this case, I think Dr. Jauhar passed the test. Final question for the committee: Should we allow Dr. Jauhar to remain a member? All in favor raise your hands.” Most hands went up, I’m happy to say.

  CHAPTER EIGHTEEN

  bloody penguins

  Don’t just do something. Stand there!

  —I C U MAXIM

  After almost four months as a second-year, I was beginning to get comfortable with the job. But I did not want to go back to the intensive care unit, which I had last rotated through almost one year earlier. “Maybe it’ll be different this year,” Sonia said, flipping through a magazine as we watched HBO one Sunday night. After all, I was no longer an intern. “Maybe,” I replied skeptically.

  My father-in-law called to buck up my spirits. “Critical care is simple,” he said with characteristic nonchalance. “There are only a few things to keep track of: blood pressure, oxygenation, fluid status.” In his world, patients were defined by their physiologies, a concept that did not comfort me.

  The main reason for my reluctance, though I didn’t want to admit this to anyone—least of all Sonia’s father—was that I did not want to carry the code beeper. All through residency I had dreaded the day I would have to be a code leader—the one who resuscitates patients, the fearless leader barking orders, making snap judgments, saving lives. Somehow it seemed beyond my capabilities.

  I phoned Rajiv for some words of encouragement. “Just be sure you’re not the first one to get to a code,” he said, chuckling. That was the extent of his advice.

  That night in bed, my mind drifted back to medical school and my first code, on my first clerkship in internal medicine at the St. Louis VA Medical Center. Early one morning, I was dozing in the call room when a high-pitched chirp awakened me. I reached in the dark for my beeper, randomly pushing buttons until a number appeared on the display. When I punched the number in and was connected, a nurse informed me that a code was going on in the surgical intensive care unit. She had tried paging me several times, as I had requested before going to bed, but apparently I had slept through her calls, as well as an announcement on the hospital intercom. Shit, I thought, jumping out of bed. How is this going to look for my grade! Throwing on my white coat, I raced downstairs. I passed through a set of double doors and sprinted down a long hallway, spilling paraphernalia from my pockets along the way, before arriving in the ICU. It was a brand-new ward, brightly lit, a modern affair. Under an intense ceiling lamp, a rather long man was being resuscitated by a group of doctors and nurses. His skin was dry, scaly, dirty-looking. He must have had cirrhosis because his belly was horribly distended; even his belly button protruded outward. Black fecal matter was smeared on the mattress. I stood off at a distance, my eyes watering from the stench, hoping no one would call on me. A senior resident was running the code. “Okay, hold compressions,” he said casually, almost like a photographer giving instructions at a group portrait. He stared at the monitor. “All right, he’s still fibrillating. Push another round of epinephrine and charge up the paddles.”

  “Oh, let him die already!” a nurse cried out. She was riding the dying man’s chest, thumping up and down on his sternum with her short arms. The code leader just chuckled and continued to give orders. There was no fear or urgency in his voice. He might as well have been directing an exercise on a mannequin.

  After a few minutes, resuscitation efforts ceased and the patient was pronounced dead. I went back to my call room, but for the remainder of the night I couldn’t sleep. I kept thinking about the code, not so much about the dead patient as about the code leader. He had been so calm, so cool, so composed under pressure. How was I ever going to be like that?

  Besides codes, there were other reasons I didn’t want to work in the ICU. Though I was almost halfway through residency, I still wasn’t sure whether I even believed in intensive care. So much of what doctors did in the ICU seemed to be of marginal benefit, action for no good, clear, definable purpose. In the ICU, doctors were prone to an irrational compulsion to do something—anything—no matter how futile or inane. It was a reflexive impulse, like taking a step backward if someone yells out “X-ray!”—regardless of where you are standing. It didn’t seem to matter that clinical data was often incomplete or difficult to interpret. The stakes were high, the patients were sick, and you were supposed to act with conviction, even if there was no basis for it. And the therapies employed were hardly benign. Ventilators caused pneumonia, intravenous pressors caused arrhythmias, central lines caused infections and collapsed lungs, bed confinement caused blood clots and deconditioning. And what to say of the noise, the stress, the sleep deprivation? Primum non nocere. It was a fundamental dictum, a boundary never to be crossed, but in the ICU sometimes it was impossible to do no harm.

  One thing I had learned the last time I had been in the ICU was that it wasn’t just doctors who hurt patients. More often than not, it was their families. I thought of Rose Reynolds, a nonagenarian who had been admitted to the pulmonary ward in the winter with a bad case of pneumonia. On her first night in the hospital, I asked her family if they wanted to make her DNR. Frankly, I wasn’t sure she’d even survive the night. “No,” her son, a lawyer, replied. “We want heroic measures to keep her alive.”

  Just before her ninety-second birthday, she was transferred to the ICU. When I saw her next, almost two months later, she was still there. She had suffered numerous complications during her prolonged stay, including respiratory failure, congestive heart failure, and a severe abdominal infection, but she was still alive, though it was hard to tell where her body ended and the tubes began.


  “We want her kept alive indefinitely,” her son, speaking for his three siblings, said on more than one occasion. One afternoon, my classmate Cynthia stormed into the conference room in tears. She had just performed the weekly ritual of replacing Reynolds’s intravenous catheters with fresh, sterile ones. “What are they thinking?” she cried, frustrated that Reynolds’s family had once again refused to discuss DNR. “They must really hate their mother!”

  In the ICU, one gets accustomed to families that push, that focus on the tiny upticks in a patient’s condition, even in the face of inexorable decline, but Reynolds’s family stood out in their zealotry. Her condition never fluctuated; there were no peaks or plateaus to justify hope. “Let her die,” I yearned to tell them. “What you are doing is much worse than death.” Behind their backs, the nurses whispered that they were probably compensating now for care they had not provided earlier.

  When her heart finally stopped one Sunday evening, my senior resident Reva ran the code. “Should we start chest compressions?” I said breathlessly when I entered the room. “In a minute,” Reva replied. Her tone told me everything I needed to know. This was going to be a “slow code.” A nurse filled a syringe with epinephrine, meticulously flicking the plastic barrel with her forefinger to get rid of the bubbles. Then she turned to Reva and signaled that the drug was ready, should we decide to use it. Reva gazed at the monitor. The squiggles of ventricular fibrillation had dampened to an almost flat line before we started CPR. With the slightest bit of pressure, I heard a sickening crunch, as Reynolds’s calcified ribs cracked like eggshells under the weight of my arms. “Not so hard,” Reva scolded me. “We don’t want to hurt her.”

  We went through the motions of a code, performing shallow chest compressions. After about ten minutes, Reva said, “Let’s call it. Are we all agreed?” and the nurse and I nodded. We went out to the waiting room to talk to the family. “I’m sorry, but she didn’t make it,” Reva told them matter-of-factly. “We tried but we could not resuscitate her.” The children stared at us blankly. The son who had insisted on heroic measures walked out, taking out a cell phone.