Intern (34 page)

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 not 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.

Don't just do something. Stand there!

—
I C U MAXIM

 

A
fter 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.

A few minutes later, he stopped me near the conference room. “What happened in there?” he asked pointedly.

My face flushed. “What do you mean?”

“I mean, was there a chance?”

“No,” I replied. “There was no chance.” Of that much I was certain.

He looked perplexed. “But I thought resuscitation meant that you could keep her alive indefinitely. Couldn't you have put her on a heart-lung machine?”

WHEN I ARRIVED
in the ICU Monday morning to start the monthlong rotation, the team had already assembled in the conference room. There were two third-year residents, two second-years (including me), four interns, and a medical student. I had worked with some of them before, and despite my polemic against ICU medicine in the
Times
a few months back, they greeted me with friendly nods. I smiled nervously, aware that we were about to embark on an intimate adventure together. Sonia later told me that when she worked in the ICU, the women on her team developed such intense camaraderie that their menstrual periods got synchronized—in less than a month.

The attending physician was Omar Morales, the pockmarked Puerto Rican who was adored by the house staff for his teaching and for his blunt, if impolitic, opinions. If patients grimaced, he would tell them to smile. If they groaned, he would turn exasperatedly to the house staff and say, “Why is he doing that?” Once, when a patient with blood clots in her lungs didn't want her oxygen turned off, claiming to still be short of breath, Morales ordered us to turn it off anyway, saying she was just “addicted to the noise.” Another time, I was told he referred to a patient as a cockroach because she had managed to survive yet another cardiac arrest.

When Morales arrived at eight o'clock that morning, we started our rounds. There was a patient with AIDS who had respiratory, kidney, and heart failure, and was also deaf, blind, and comatose. His brother, residents whispered, was keeping him alive to collect his Social Security checks. There was an unconscious woman with terminal leukemia whose family wanted to withdraw care, but her estranged husband, who reportedly had beaten her, wouldn't permit it. Another man had fallen off a bicycle and gone to an emergency room, where a doctor sent him home without checking for a vertebral fracture. Now he lay awake, paralyzed from the neck down, staring up at the ceiling.