Intern (32 page)

I remembered how the cardiology fellow used to obtain “informed consent” for procedures on 4-North. He told the patients the risks and benefits, but rarely did this prompt any sort of meaningful discussion. Patients invariably told him, “You're the doctor. I'll do whatever you say.” Most of them seemed to think informed consent was a sham, demanding they either ratify decisions that had already been made or make decisions they were not equipped to make. Even when patients were not agreeable, they could easily be persuaded to change their minds, like the Mexican man who was bullied into having a catheterization against his better judgment. The words Dr. Klein, the attending physician, had used after wresting consent from him were emblazoned in my memory. He said we could get whatever we wanted from patients. “As long as they agree with us, they're not crazy.”

The next night, around 3:00 a.m., I stopped by Armen Izanian's room to see how he was doing. I expected to find him asleep, but when I peeked in, he was sitting bolt upright in bed, eyes closed, hands folded, in an almost meditative pose. A pressurized mask was strapped tightly to his face, its plastic straps digging deeply into his neck. A machine whooshed like a steam engine with each breath. His wife, Anna, was standing at his bedside, stroking his perspiring forehead. Feldman, an intern, was also in the room. He was a young punk with pointy eyebrows who talked so fast he stammered. He had a reputation for being a cowboy, confident and cocksure.

“Who called you?” he demanded when he saw me in the doorway.

I told him I had admitted Izanian the previous night and wanted to see how he was doing.

“Well, look at him!” Feldman exclaimed, walking out into the hallway. Izanian was breathing over forty times a minute. Though he was receiving pure oxygen, his pulse oximeter was reading only 90 percent, critically low.

“He probably has pneumonia,” Feldman said. “The chest X-ray
shows a new infiltrate.” This did not surprise me. Lung tumors can obstruct the breathing passages, causing fluid and secretions to build up, a disorder called postobstructive pneumonia.

Wondering why he hadn't called me for backup, I asked Feldman which treatments he had given Mr. Izanian so far.

“Lasix, Solumedrol, Atrovent, albuterol,” Feldman replied rapid-fire, counting out the interventions on his skinny fingers. “But he's getting tired. I think he's going to crap out pretty soon.”

“Have you called the ICU?”

“He's DNR!” Feldman cried indignantly. “Right now, I just want to keep him comfortable.”

I assumed the DNR order had been issued earlier in the day. “Did you start antibiotics?”

Feldman shook his head, as if the thought had occurred to him but he had decided it wasn't worth it.

“DNR doesn't mean we're not going to treat him,” I snapped. “Start him on broad-spectrum antibiotics. Let's see if we can get him through this.”

As Feldman headed over to the nursing station, I heard his beeper go off.
Beep . . . beep . . . beep.
The sound transported me back to a year ago, when I had been the night float at Memorial. For a moment I felt a pang of sympathy for him. Night float during internship had almost broken me; I was thankful those days had long passed. But from what I could remember of it, I was certain that the last thing Feldman wanted to do that night was spend precious time on a patient who was DNR.

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 intubation,” 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?”