- Email: [email protected]
In Dante's ninth circle
Patient Education and Counseling 84 (2011) 31–32
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Reflective Practice
In Dante’s ninth circle§ William T. Branch Jr.* Division of General Medicine, Emory University School of Medicine, USA
A R T I C L E I N F O
Article history: Received 16 September 2009 Received in revised form 20 May 2010 Accepted 4 June 2010
Struggling for an excuse, I explained to the man on the phone that I was cutting back on my practice. I had taken the call because it came from my hometown. Now the caller, Walter, played his trump card, ‘‘I was having dinner with an old friend of yours on Saturday. He told me I must get you to be the doctor for my brother.’’ Stuck, I suggested a compromise. I would arrange for his semi-comatose brother’s transfer to our University Hospital where he would receive care from our hospitalist team. I would look in on him frequently and be available to advise the family. Weeks later, two highly competent and delightfully cooperative hospitalists, both former residents in my program, had alternated caring for our patient, call him Mr. X, according to their four-day rotations. Every few days, I had attended a family meeting in a small conference room adjacent to the MICU. The patient’s next of kin was Alice, his daughter, an extremely nice and concerned, unmarried fortyish lady. Alice invariably deferred to her attorney uncle, Walter. Mr. X was only responsive to pain, was ventilatordependent, subject to hypotension and congestive heart failure during frequent bouts of atrial fibrillation, and responding slowly if at all to multiple antibiotics administered empirically for pulmonary infiltrates. There was no good explanation for why a previously robust small town shop-owner had reached this state following an elective hip replacement at his regional hospital. We suspected aspiration, plus atrial fibrillation, hypotension, and heart failure had caused unobserved anoxic brain damage. In the meetings, the family expressed relief that he was now in the hands of ‘‘experts’’, and asked that everything possible be done.
§ For more information on the Reflective Practice section please see: Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Education and Counseling 2004;54:251–253. * Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta, GA 30303, USA. Tel.: +1 404 778 1600; fax: +1 404 778 1602. E-mail address: [email protected].
0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.06.007
I assured them that everything was being done, but cautioned that his condition remained grave. Following weeks of effort by the MICU team, spearheaded by my two hospitalist colleagues, pulmonary infiltrates partially resolved, but our patient developed renal failure, and more episodes of atrial fibrillation and hypotension. There were two failed efforts to wean him from the ventilator. The patient remained mostly unresponsive. The intensivist consultant and nursing staff increasingly asked if treatments held any realistic hope for recovery. Both hospitalists stuck with me in terms of doing what I thought was best. Alice wanted us to keep trying but was open to ceasing our efforts if there was truly no hope. Walter was determined not to ‘‘give up’’. The patient had no living will, no living spouse, no previously expressed wishes, and of course, could not speak for himself. Walter had but one request, ‘‘Get my brother well enough so he can watch one more football game, even if he’s in a bed in a rehab, even if he hasn’t long to live after that.’’ The MICU consultant became sarcastic, ‘‘Why are we torturing this man?’’ Walter developed a loathing for this consultant, ‘‘Who does he think he is, God? It’s not his brother lying there.’’ Weaning failed again. The patient’s creatinine reached the level of dialysis. I intervened to ask the renal team to hold off for a few days. The situation needed to be resolved. The vehicle for resolution entailed me meeting with the family. I placed calls to the brother and daughter. Both readily agreed to a family meeting that would also include the hospitalist currently responsible for care and head nurse in the MICU. I began laying groundwork for the meeting. ‘‘You know we’ve tried just about everything and nothing is working.’’ ‘‘I can only imagine even though barely responsive, how much he must be suffering.’’ I had made my decision, but why? Why so difficult for me to extubate Mr. X. Why make this decision? I could have gone longer with the respirator. Renal was prepared for dialysis. If I asked, hospitalists would continue his care. Yet I felt no other choice, like walking down a road with no exit. More than a decade earlier, I had extubated a patient and watched him die. A seventy-nine-year-old man was made DNR in discussion with his family after he had perforated a diverticular abscess. Antibiotics failed to control massive peritonitis. I agreed to a last ditch surgical effort, which failed. But the patient, who had arrested while undergoing anesthesia, returned to us on the ventilator. I say I extubated him, but akin to an army colonel ordering his lieutenant to lead troops into battle, what I did was instruct and then observe a surgical resident remove the
32
W.T. Branch Jr. / Patient Education and Counseling 84 (2011) 31–32
endotracheal tube. Difficult to convey is the feeling of dread I felt as this former patient expired. The feeling seemingly arose from deep within my psyche. It was as though I had crossed a fearful boundary. For several minutes, I was metaphorically in the Inferno. Again, using a military analogy, I had moved forward as though without choice. I felt like a soldier crossing no man’s land on a dark night. About a year later while seeing me as a patient, that former patient’s wife said she needed to talk about her husband’s death. Momentarily, I re-experienced the feeling of dread. Half expecting her to say, ‘‘I’ve never been able to live with the decision,’’ I prepared to take the blame on myself. To my surprise, she said, ‘‘Thank you. Thank you so much for being strong. You prevented such a horrible outcome.’’ That helped but did not assuage my discomfort. It seemed illogical, but actively facilitating the death even of a dying, suffering patient, was being judged by my conscience as wrong. Now, I prepared to repeat the experience. What drove me forward? Some equally deeply felt mandate, something I must do. Despite what felt like peril to my soul, I needed to relieve Mr. X’s now completely pointless suffering. Subsequently reflecting on this, I know that my part was not an intellectual decision, not an elegant bit of moral reasoning, balancing to do no harm and giving autonomy to the surrogates with justice and benevolence. No, in the existential condition of being Mr. X’s doctor, I needed to stop his pointless suffering. We met. It was eight or nine o’clock at night. I covered the history of Mr. X’s illness, his hospitalization and treatments–all of which had been to no avail. I concluded by saying it was time to end his suffering. My hospitalist colleague agreed. The head nurse spoke in sympathy. Alice agreed. Walter was not happy but acquiesced. We took our time. We empathized, listened to stories about Mr. X’s life, answered questions. The nurse being with us was hugely helpful. She was gentle, and had no qualms about the decision. Enormously compassionately, she explained the sequence of light sedation prior to extubation that would quell any anxiety and allow a natural death as Mr. X gradually ceased breathing on his own.
That was the way it happened. Alice stayed throughout his passing, which took several hours. Walter said nothing more and left after the meeting. I think a lot about these two cases. I believe there’s a fundamental morality to being human. My involvement with extubation of ventilator-dependent patients brought me face to face with two deep-seated though incompatible inner mandates. One said not to kill; the other to relieve suffering. I treated my patient until I was sure there was no hope for recovery. Only then did I relieve his suffering by extubating Mr. X. That final act felt Kierkegaardian, fear and trembling and sickness unto death come to mind. If my decisions were based on fundamental human values, others who supported me, I believe, to one degree or another, experienced the same. I am not advocating imposing a moral decision based on one person’s conscience. One must be humble in these matters. Our collective decision around the table on that night was socially and legally acceptable and could be defended by moral reasoning. And, how ever deep-seated the nature of my distress, the extubation of Mr. X was less dreadful to me than my first extubation. I was not getting used to extubating people. It helped to hear his family’s heart-felt stories. It helped to identify with Mr. X as a suffering person. Three years passed since I extubated Mr. X. I received a Holiday card. The return address was from my home town. My wife asked me, ‘‘Who is Walter? Do we know a Walter?’’ The card read, ‘‘I want to thank you. You’ll never know how much you did for me and my family. You are forever in my prayers. With gratitude, Walter.’’ It took a moment for me to remember him; after all, I had not expected to receive his card. It assuaged me greatly to receive it. Walter’s card had made the circle whole. Acknowledgements Author is the sole contributor to this manuscript. There are no conflicts on interest. Changes in manuscript details have disguised participants in the events. This manuscript has no source of funding.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Reflective Practice
In Dante’s ninth circle§ William T. Branch Jr.* Division of General Medicine, Emory University School of Medicine, USA
A R T I C L E I N F O
Article history: Received 16 September 2009 Received in revised form 20 May 2010 Accepted 4 June 2010
Struggling for an excuse, I explained to the man on the phone that I was cutting back on my practice. I had taken the call because it came from my hometown. Now the caller, Walter, played his trump card, ‘‘I was having dinner with an old friend of yours on Saturday. He told me I must get you to be the doctor for my brother.’’ Stuck, I suggested a compromise. I would arrange for his semi-comatose brother’s transfer to our University Hospital where he would receive care from our hospitalist team. I would look in on him frequently and be available to advise the family. Weeks later, two highly competent and delightfully cooperative hospitalists, both former residents in my program, had alternated caring for our patient, call him Mr. X, according to their four-day rotations. Every few days, I had attended a family meeting in a small conference room adjacent to the MICU. The patient’s next of kin was Alice, his daughter, an extremely nice and concerned, unmarried fortyish lady. Alice invariably deferred to her attorney uncle, Walter. Mr. X was only responsive to pain, was ventilatordependent, subject to hypotension and congestive heart failure during frequent bouts of atrial fibrillation, and responding slowly if at all to multiple antibiotics administered empirically for pulmonary infiltrates. There was no good explanation for why a previously robust small town shop-owner had reached this state following an elective hip replacement at his regional hospital. We suspected aspiration, plus atrial fibrillation, hypotension, and heart failure had caused unobserved anoxic brain damage. In the meetings, the family expressed relief that he was now in the hands of ‘‘experts’’, and asked that everything possible be done.
§ For more information on the Reflective Practice section please see: Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Education and Counseling 2004;54:251–253. * Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, 49 Jesse Hill Jr. Drive, Atlanta, GA 30303, USA. Tel.: +1 404 778 1600; fax: +1 404 778 1602. E-mail address: [email protected].
0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.06.007
I assured them that everything was being done, but cautioned that his condition remained grave. Following weeks of effort by the MICU team, spearheaded by my two hospitalist colleagues, pulmonary infiltrates partially resolved, but our patient developed renal failure, and more episodes of atrial fibrillation and hypotension. There were two failed efforts to wean him from the ventilator. The patient remained mostly unresponsive. The intensivist consultant and nursing staff increasingly asked if treatments held any realistic hope for recovery. Both hospitalists stuck with me in terms of doing what I thought was best. Alice wanted us to keep trying but was open to ceasing our efforts if there was truly no hope. Walter was determined not to ‘‘give up’’. The patient had no living will, no living spouse, no previously expressed wishes, and of course, could not speak for himself. Walter had but one request, ‘‘Get my brother well enough so he can watch one more football game, even if he’s in a bed in a rehab, even if he hasn’t long to live after that.’’ The MICU consultant became sarcastic, ‘‘Why are we torturing this man?’’ Walter developed a loathing for this consultant, ‘‘Who does he think he is, God? It’s not his brother lying there.’’ Weaning failed again. The patient’s creatinine reached the level of dialysis. I intervened to ask the renal team to hold off for a few days. The situation needed to be resolved. The vehicle for resolution entailed me meeting with the family. I placed calls to the brother and daughter. Both readily agreed to a family meeting that would also include the hospitalist currently responsible for care and head nurse in the MICU. I began laying groundwork for the meeting. ‘‘You know we’ve tried just about everything and nothing is working.’’ ‘‘I can only imagine even though barely responsive, how much he must be suffering.’’ I had made my decision, but why? Why so difficult for me to extubate Mr. X. Why make this decision? I could have gone longer with the respirator. Renal was prepared for dialysis. If I asked, hospitalists would continue his care. Yet I felt no other choice, like walking down a road with no exit. More than a decade earlier, I had extubated a patient and watched him die. A seventy-nine-year-old man was made DNR in discussion with his family after he had perforated a diverticular abscess. Antibiotics failed to control massive peritonitis. I agreed to a last ditch surgical effort, which failed. But the patient, who had arrested while undergoing anesthesia, returned to us on the ventilator. I say I extubated him, but akin to an army colonel ordering his lieutenant to lead troops into battle, what I did was instruct and then observe a surgical resident remove the
32
W.T. Branch Jr. / Patient Education and Counseling 84 (2011) 31–32
endotracheal tube. Difficult to convey is the feeling of dread I felt as this former patient expired. The feeling seemingly arose from deep within my psyche. It was as though I had crossed a fearful boundary. For several minutes, I was metaphorically in the Inferno. Again, using a military analogy, I had moved forward as though without choice. I felt like a soldier crossing no man’s land on a dark night. About a year later while seeing me as a patient, that former patient’s wife said she needed to talk about her husband’s death. Momentarily, I re-experienced the feeling of dread. Half expecting her to say, ‘‘I’ve never been able to live with the decision,’’ I prepared to take the blame on myself. To my surprise, she said, ‘‘Thank you. Thank you so much for being strong. You prevented such a horrible outcome.’’ That helped but did not assuage my discomfort. It seemed illogical, but actively facilitating the death even of a dying, suffering patient, was being judged by my conscience as wrong. Now, I prepared to repeat the experience. What drove me forward? Some equally deeply felt mandate, something I must do. Despite what felt like peril to my soul, I needed to relieve Mr. X’s now completely pointless suffering. Subsequently reflecting on this, I know that my part was not an intellectual decision, not an elegant bit of moral reasoning, balancing to do no harm and giving autonomy to the surrogates with justice and benevolence. No, in the existential condition of being Mr. X’s doctor, I needed to stop his pointless suffering. We met. It was eight or nine o’clock at night. I covered the history of Mr. X’s illness, his hospitalization and treatments–all of which had been to no avail. I concluded by saying it was time to end his suffering. My hospitalist colleague agreed. The head nurse spoke in sympathy. Alice agreed. Walter was not happy but acquiesced. We took our time. We empathized, listened to stories about Mr. X’s life, answered questions. The nurse being with us was hugely helpful. She was gentle, and had no qualms about the decision. Enormously compassionately, she explained the sequence of light sedation prior to extubation that would quell any anxiety and allow a natural death as Mr. X gradually ceased breathing on his own.
That was the way it happened. Alice stayed throughout his passing, which took several hours. Walter said nothing more and left after the meeting. I think a lot about these two cases. I believe there’s a fundamental morality to being human. My involvement with extubation of ventilator-dependent patients brought me face to face with two deep-seated though incompatible inner mandates. One said not to kill; the other to relieve suffering. I treated my patient until I was sure there was no hope for recovery. Only then did I relieve his suffering by extubating Mr. X. That final act felt Kierkegaardian, fear and trembling and sickness unto death come to mind. If my decisions were based on fundamental human values, others who supported me, I believe, to one degree or another, experienced the same. I am not advocating imposing a moral decision based on one person’s conscience. One must be humble in these matters. Our collective decision around the table on that night was socially and legally acceptable and could be defended by moral reasoning. And, how ever deep-seated the nature of my distress, the extubation of Mr. X was less dreadful to me than my first extubation. I was not getting used to extubating people. It helped to hear his family’s heart-felt stories. It helped to identify with Mr. X as a suffering person. Three years passed since I extubated Mr. X. I received a Holiday card. The return address was from my home town. My wife asked me, ‘‘Who is Walter? Do we know a Walter?’’ The card read, ‘‘I want to thank you. You’ll never know how much you did for me and my family. You are forever in my prayers. With gratitude, Walter.’’ It took a moment for me to remember him; after all, I had not expected to receive his card. It assuaged me greatly to receive it. Walter’s card had made the circle whole. Acknowledgements Author is the sole contributor to this manuscript. There are no conflicts on interest. Changes in manuscript details have disguised participants in the events. This manuscript has no source of funding.