A Doctor's Dilemma
It was my first day at my new job, practicing a new specialty. Having spent fourteen years as an ICU physician--including a four-year pulmonary/critical-care fellowship in this very hospital--I had just completed a palliative-care fellowship. Now I was the hospital's palliative-care consult attending.
When I set eyes on the patient in room 1407, my first thought was: THIS LADY NEEDS TO BE INTUBATED--STAT!
The only trouble was that my job was to ease this patient's passing, not to prolong her life.
The team had told me that Mrs. Zelnick, an eighty-two-year-old widow, was dying from pneumonia and didn’t want to be put on life support.
What a breath of fresh air, I'd thought. Too often, as an ICU physician, I'd been tasked with keeping dying patients alive--here, I was being asked to honor an elderly woman's request to die in peace.
But it wasn’t going to be that simple.
Mrs. Zelnick, a beautiful woman who bore a striking resemblance to Anne Bancroft, somehow remained elegant even in her distress.
Her chart documented a surprisingly benign medical history: she'd suffered no real medical problems until a few days back, when she'd been brought to the emergency room for a bowel obstruction.
Over the next three days, while the obstruction was clearing up, a pneumonia had blossomed.
Now I noted Mrs. Zelnick's confusion, rattling breath and blue lips--clear signals of respiratory distress. This was not good.
A Filipino woman sat at the bedside, crying softly.
I introduced myself and asked, "How do you know Mrs. Zelnick?”
In faltering English, she explained that she had been Mrs. Zelnick’s housekeeper for the past eight years. When Mr. Zelnick had died, three years ago, she had moved into the home at Mrs. Zelnick’s request.
“She was all alone. Lonely. When he died, she had no children, no friends. She was always so sad and didn’t want to talk much. I tried to cheer her up, but...." She shrugged sadly, then lifted up Mrs. Zelnick’s forearm and pointed to a line of numbers tattooed on the inner side.
My heart dropped. This woman was a Holocaust survivor. She looked like my grandmother, the archtypal Jewish grandmother. Something inside me melted. I wanted to pick her up, to cradle her. I longed to shield her with my own body from all her suffering, past and present.
And I didn’t yet know the half of it.
Scanning Mrs. Zelnick's chart, I learned that she had been imprisoned at Auschwitz, where she had fallen victim to Dr. Mengele's insane "experiments." He had removed her uterus, leaving her with embarrassing abdominal disfigurement and intermittent small-bowel obstructions. Her twin sister had perished, along with her entire family. After the war, while in a displaced persons camp, she'd married another survivor, and they had eventually made it to safety in America.
A firestorm was raging in my head. Pneumonia is treatable...if we put Mrs. Zelnick in the ICU and gave her respiratory support and antibiotics, she could be back to normal in a few days.
But I felt confused and rudderless. What type of doctor was I supposed to be--one who would bring this patient comfort but perhaps miss a chance to save her life, or one who would, in trying to save her life, inflict painful and terrifying treatments upon her--treatments that she'd supposedly refused?
Palliative care is famous for providing less aggressive care without hastening patient mortality. Here and now, if things went badly, I might singlehandedly reverse that trend. Not a good move, your first day at a new job.
I called Mrs. Zelnick's primary medical team, and we huddled outside her room.
“She wasn’t improving,” the young attending explained. "I told her that she could either have a tube placed down her throat and go to the ICU, or go to the palliative-care suite and be comfortable. She wanted to be comfortable."
"But do you think she understood?” I asked, trying not to sound judgmental. “She has high C02 levels; she's confused. Also, she’s a Holocaust survivor. She’s probably terrified of anyone doing anything to her. Maybe we should just sedate the hell out of her and intubate.”
Clearly, the team found my words distressing. They too had struggled with this case--and they'd made a choice. The morphine they'd administered had eased Mrs. Zelnick's shortness of breath. She was quieter, more peaceful than before, and they were feeling relieved. They had called me in to support their decision and help ease the patient's passing. Instead, I was making it harder.
“I’m just not comfortable intubating her,” said the attending. “I feel like she was awake enough to understand me when she made her decision.”
There was some murmuring.
“I’m not sure she really got it,” the respiratory therapist piped up.
“Look,” said the attending. “I spent fifteen minutes with her, I did the best I could to persuade her, and she really didn’t want the tube. I would feel like I was going against her wishes if she got intubated.”
“Would you consider trying noninvasive ventilation overnight?” I asked desperately. Maybe a tightly fitted mask would be enough to turn her around.
But it turned out that we'd need an ICU bed to go that route, and the ICU attending refused, saying that the beds had to go to several ER patients who needed breathing machines and who had expressed a wish to be resuscitated if need be.
I was at a loss. Mrs. Zelnick was too sick to stay on this floor, but too close to death to go to the ICU.
At that moment, the respiratory therapist tapped me on the shoulder. "Let's at least try the mask. I’ll be on most of the night, and I'll keep an eye on her.”
Later that evening, I slunk out of the hospital. Had I made everything worse? Mrs. Zelnick was still confused and uncomfortable. The team was upset with me. And I was doing something that I'd been trained never to do--use noninvasive ventilation on a patient who wasn’t fully alert.
The next morning, my worst fears were realized. Delirious and terrified, Mrs. Zelnick writhed in the bed, her mask off-center and totally ineffective.
"I tried all night to keep her mask on," the nurse said, "but she keeps pulling it off. She’s afraid that she'll suffocate."
I knew that I couldn’t save Mrs. Zelnick without full ICU care--and I didn’t know if she'd even want us to try. Was I projecting my own values onto someone who legitimately preferred to die in comfort?
I made a decision: I would be a palliative-care doctor. I would not increase Mrs. Zelnick's suffering again. I had the expertise to keep her comfortable, and now I would use it.
I called the palliative-care floor. “We have a patient coming up. Please prepare a morphine drip.”
Mrs. Zelnick died comfortably four hours later, as I held her hand.
I still wonder: What was the right approach? And I still don’t know the answer.
Although patient-centered care is everyone’s goal, many things can get in the way. The medical attending and I had disagreed on Mrs. Zelnick's treatment. He was earnest, young, and he wanted her suffering to stop, whereas my opinion was colored by my previous critical-care training and by my intense resonance with her history. She was part of my tribe.
I know that we all wanted the best for Mrs. Zelnick. I just wish I could be sure that we'd known what that was.
About the author:
Jessica Nutik Zitter is a physician practicing pulmonary/critical-care and palliative-care medicine. She works at Highland Hospital in Oakland and is an assistant clinical professor at University of California, San Francisco. Her work has been published in the New York Times, San Francisco Chronicle, JAMA and The Atlantic Monthly. Her website is jessicazitter.com.