Doctored (10 page)

I dispatched a resident to fetch a nurse's aide.

“Last time I went in the bed, the man came in and said, ‘Do you do that on yourself all the time?'” She shifted uncomfortably. “They'd better hurry or there's going to be another accident.”

I sat down in the chair next to her bed and leafed through her chart. John and Simon, our fellow for the month, remained standing, waiting for me to initiate the conversation. She had been in the hospital for over a week. “Feels like three years,” she said. “During the day, it's hot as Hades. At night you can chip off the icicles.” Relieved of excess water weight, she was forty pounds lighter than she'd been on admission, breathing much better but still feeling weak with even a tiny bit of exertion.

“Have you been getting out of bed at all?” I asked her, turning a page.

“Not recently.”

“Not even to the bathroom?”

She shook her head.

“Where do you go?”

“Unfortunately, in the diaper.”

At home she'd been able to do most activities of daily living—bathing, dressing, preparing meals—though she'd been housebound. “I didn't want to go out,” she explained. “I was feeling very down.”

“Well, that will hopefully change now that it's getting warmer,” I said. “It's been a rough winter. I've been a little depressed myself,” I added frivolously.

She perked up. “Who hugs you, Doctor?”

I laughed. “No one.” The sheer arduousness of taking care of a newborn had sapped the romantic energy at home.

“Don't look at me,” John quickly interjected.

“I'll give you a hug,” she said.

Embarrassed, I shook my head. “No, that's all right.”

“No, it's not all right. Come here. Give me a hug.”

She struggled to sit up, swaying from side to side to pull up her three hundred or so pounds. Then she grabbed hold of me. “If you get fifteen hugs a day, all your problems will be solved.”

“I wish it were that easy,” I said as she squeezed the air out of me.

“No, I'm serious,” she said. “A hug does something to your inside.” (No question about that, I thought, feeling my spleen being crushed.)

After breaking from her clench, I had her sit up so I could listen to her chest. Her thick gray chin hairs tickled the back of my hand. She smelled of cheap perfume, but the odor was inoffensive, even slightly pleasant. While I was examining her, she glanced at Simon, the cardiology fellow, standing quietly behind me.

“What do you want to be when you grow up?” she asked him.

“I'm training to be a heart doctor,” he replied stiffly. “I have a couple more years.”

“I wanted to be a photographer's model,” she said. We all laughed, except Simon. “Do you like old movies?” she asked him.

“Sometimes,” he replied, rocking nervously on his feet.

“Well, I love those old Betty Grable movies. And Marilyn Monroe, too. Did you know me and Elizabeth are only three months apart?”

“Elizabeth?” Simon said.

“Yes, Elizabeth Taylor. But we're different. I only had one husband.” Simon stared at her impassively. “He was a good man,” she went on. “He said, ‘I'm the husband. I don't want you to work.'”

“What did you do?” I asked.

“I didn't work! What was I going to do, argue? Someone tells you, ‘I'll support you,' what would you do?”

An orderly arrived with a bedpan. I told Ms. McAllister that we would come back to see her the next day.

“Okay,” she said, turning onto her side so the receptacle could be placed under her bottom. She looked straight at Simon. “Smile, sweetie. It only gets worse when you get older.”

*   *   *

Those first few months at LIJ, I frequently assumed attending duties in the cardiac care unit. Most of my cases were straightforward, but a few required a subtle touch. Dick Perkins, a middle-aged construction executive, was admitted to the CCU one Saturday night after a prolonged bout of chest pain. Blood tests showed he had suffered a moderate heart attack, in which blood flow to the heart muscle is cut off by a coronary blockage. But when he was told he needed a coronary angiogram, he balked. “He doesn't want any invasive procedures,” a bedraggled nurse explained when I arrived for rounds on Sunday morning.

I had encountered such resistance many times. “I'll talk to him,” I said. Patients are often anxious about cardiac catheterization, and a discussion of the risks and benefits usually allays their fears. But the nurse said Mr. Perkins had been ranting and uncooperative with blood draws and blood pressure checks. A psychiatrist, asked to assess decision-making ability, had deemed him incapacitated—he seemed to have paranoid delusions about his medical condition—and suggested forcibly treating him, if necessary.

I walked into his room, hoping to avoid a showdown. He was standing with his back to me, talking on a cell phone. When he heard me, he hung up and turned around; he was an overweight man with a sallow, jowly face and a potbelly, wearing Dockers and a blue oxford cloth shirt. I extended my hand. “Hi, I'm Dr. Jauhar,” I said. “I'm the cardiologist on call for the weekend.”

He eyed me suspiciously but reluctantly shook my hand. I asked him to sit down, but he remained standing, arms folded, with a fixed and fervent look.

“You've had a heart attack,” I started off.

“So you say,” he shot back.

“Well, this is something I can say with confidence,” I replied, trying to project authority. “I'm told you're a building expert. I know next to nothing about buildings, so anything you tell me I am likely to believe. Similarly, I think you should trust me if I tell you that you've had a heart attack. After all, I know how to identify heart attacks. It's what I do.”

I asked someone to pass me a printout of his test results. After I showed him the abnormal cardiac enzyme levels, he sneered and said: “Fine. So you think I had a heart attack.” Clearly, he still did not believe me.

“The best treatment for a heart attack is angioplasty,” I said.

“I don't want it,” he said, his voice rising. “I told them I don't want a stent.”

“No one can force you to have it,” I said calmly. Angioplasty, in which tiny balloons and stents are used to relieve coronary blockages, wouldn't work without his cooperation, and I wasn't about to call in security guards to frog-march him to the catheterization lab. “But I think you should reconsider.”

He glared at me and said he did not want to discuss the matter further.

“Okay,” I said. “We'll watch you for another twenty-four hours. If your condition remains stable, we'll send you home.”

“No, I'm leaving now.” He moved to gather his things.

I watched him for a few moments. “You can't leave,” I finally said.

“Who says?”

I wasn't sure how to respond. “The psychiatrist,” I said tentatively.

“Which psychiatrist?” he snarled. “The little faggot with the ponytail? The little frilly guy?”

I immediately walked out to the nurses' station and phoned Mr. Perkins's son. He explained that his father had always been “strong-willed” and “done things just the way he wanted.” The behavior I was describing wasn't so different from his norm.

Now I felt even more conflicted. On the one hand, my patient clearly did not meet the standards for decision-making capacity. He did not understand his medical condition or its treatment options and the risks and benefits. If I let him sign out against medical advice and something happened to him (sudden death, another myocardial infarction), I would be liable. On the other hand, his intransigence was apparently just a part of who he was. As a doctor, I want to see my patients weigh risks and benefits in a careful, reasoned manner, use logic, have a clear sense of self, etc. In other words, I want them to think like me. But Perkins's mind operated differently from mine, and not because he was sick. Shouldn't I just allow him to be himself rather than insist on what I wanted him to be?

The situation resembled a famous medical ethics case I'd read about. In 1978, Mary Northern, a seventy-two-year-old woman in Tennessee, developed gangrene in both feet, requiring amputation. When she refused to have the surgery, doctors at Nashville General Hospital determined that she did not have decision-making capacity and filed a lawsuit for permission to amputate her legs. “Ms. Northern does not understand the severity or consequences of her disease process,” they wrote to the Department of Human Services in Nashville. “[She] does not appear to understand that failure to amputate the feet at this time would probably result in her death.”

A psychiatrist concurred, stating that Ms. Northern was generally sane but was psychotic with respect to ideas concerning her gangrenous feet. “She tends to believe that her feet are black because of soot or dirt,” he wrote. “She does not believe her physicians about the serious infection.”

Two judges from the Tennessee Supreme Court went to see Ms. Northern in the hospital. “They tell us that your feet are shriveling up like a dead person's feet,” one of the judges told her.

“No, no,” she replied, insisting she could get up and “walk all the way down to the shopping places.”

The judge asked: “If the time comes that you have to choose between losing your feet and dying, would you rather just go ahead and die than lose your feet?”

She replied: “It's possible. It's possible only if I—just forget it. I—you are making me sick talking.”

Before he left, the judge asked her, “Did you ever read the Sermon on the Mount?”

“Yes,” Ms. Northern replied.

“You remember one thing the Good Lord said?”

“What?”

“If thy eye offend thee—”

“Oh, yes, take the eye out.”

“—cast it out. If thy hand offend you, cut it off. Now, if and when your feet begin to offend you, maybe, maybe, you will remember that little verse.”

The court decided that Ms. Northern was incompetent to make a rational decision and should have her feet amputated against her wishes. “On the subjects of death and amputation of her feet, her comprehension is blocked, blinded, or dimmed to the extent that she is incapable of recognizing facts which would be obvious to a person of normal perception,” the opinion read. “If [she] would assume and exercise her rightful control over her own destiny by stating that she prefers death to the loss of her feet, her wish would be respected … But because of her inability or unwillingness to recognize the actual condition of her feet, she is incompetent to make a rational decision.” However, because of complications, the surgery was never performed. Several months later she died as a result of a clot from her gangrenous leg that migrated to a vital organ.

That afternoon I discussed the Perkins case with a member of the hospital ethics committee. “If you say he has decision-making capacity, then you have to say that he has the right of self-determination, even if you don't agree with him,” he told me. “If he lacks decision-making capacity, you first go to a surrogate. If the surrogate is unwilling to act in the patient's best interest, then courts have said that you have to do what's in your power to prevent the patient from hurting himself. So it all depends on whether you think he has decision-making capacity or not.”

I believed Mr. Perkins lacked capacity because he was unable to acknowledge that he had a serious disease or to understand the risks, benefits, and alternatives of treatment. However, there was no need for drastic measures. When I threatened to call security to keep him from leaving, he backed down. Though still refusing nursing checks and cardiac monitoring, he remained in his room overnight.

When I went to see him the following morning, his demeanor had changed. He was making laps around the unit with an orderly, still refusing telemetry monitoring, blood draws, vital sign checks, and medications, but now he seemed quite pleasant and reasonable. He told me he understood that he had a heart problem but that he wanted to go home and follow up with a cardiologist as an outpatient.

It appeared to me that he had recovered decision-making capacity, and after seeing him, the psychiatrist agreed. Though still at risk, my patient had every right to sign out against medical advice. That is exactly what he did later that day.

*   *   *

I learned to make hard decisions those first few months as an attending, but the learning curve was steep. The pressure could be overwhelming at times because mistakes often had huge consequences, and fear of malpractice—and the resulting lawsuit—were lurking just under the surface of most of my and my colleagues' dealings with patients. One morning I got a call from the emergency room. A young man—an intern, in fact, who had been on rounds on the wards—had been admitted with chest pains. Could I come to evaluate him?

The ER that morning was the usual mess of drunks, druggies, and demented old ladies pretending to read
The New Yorker
. There were the usual pressured announcements overhead (“Linda, stat to the trauma bay … Linda”). Stretchers were arranged like latticework in the corridors, and the air was suffused with stale body odor. Searching for my patient, I ran into Joe Ricci, a jovial cardiologist who practiced in Howard Beach. Ricci was always impeccably dressed and, unlike most private practice doctors, never looked as if he was in a hurry. “How are things?” he said pleasantly. “Getting used to the place?”

I said I was. In fact, I was quite enjoying my work and was finally starting to feel confident. Ricci brought up a mutual patient. “Sarah Brenner is doing very well,” he said. “I guess those drugs you're pushing really do something.” I laughed. “By the way,” he said conspiratorially, “did you see the article in the
Times
about how doctors should work on Sundays? Ridiculous, isn't it? They think we're selling shoes.”