Comfort Zone

Chapter 6

After a close encounter with a cookie she just barely managed to avoid, Miriam headed to the ICU to see Ms. V, who'd taken a turn for the worse over the day.

She checked out her blood test results (pretty bad), her oxygen levels (abysmal), and the recommendations of the specialists (bleak) before spritzing her hands with alcohol disinfectant, going to the bedside and forcing a big smile.

Ms. V's white hair was a moonburst around her wrinkled face, hissing oxygen mask covering her mouth and nose. She returned the smile nonetheless.

"Mi doctora. How are you today?" She spoke in short spurts of words, each sentence punctuated with a gasp, her breathing clearly worse than the previous day.

"I'm fine, Ms. V. How are you feeling? Does the new oxygen mask make you more comfortable?"

"A little."

Miriam sat on the edge of the bed and hugged her knees. Maybe she could convince Ms. V this time.

Two centuries ago, the American Medical Association code said that patients should be obedient to the prescription of the physician.

A half century ago, a popular weekly TV show could easily have been called "Doctor Knows Best." Dr. Marcus Welby's style of medical care is dubbed "paternalism." Like a kindly, wise father, he made the decisions for his patients, they expected him to do so, and all the TV actors and viewers were satisfied.

In 1990, Congress passed the Patient Self-Determination Act, compelling hospitals to put patients in charge of their own health decisions. They could refuse treatments they didn't want, and no one could make decisions for them without their consent. Patients were informed of their right to have advance directives, which ensured that their wishes would be carried out if they became incapacitated. These rights stemmed from the principle of autonomy, self-rule, one of the major pillars of modern medical ethics.

Paternalism was out; long live autonomy!

Miriam had been trained in modern medical ethics, and had never practiced the old style of medicine, but now she ached to tell her patient what to do, to coerce her if necessary.

"Ms. V, you know this lung infection is pretty bad," she said.

Ms. V knew.

"You're on the most powerful antibiotics and other treatments that we have, but you're still having a hard time breathing." Ms. V knew that too.

"There's a chance you'll get worse before you get better." She paused.

"If you do get worse, putting in a breathing tube might help you." Ms. V's agitated hands tried to slap away the words but Miriam pressed on.

"I know. We've had this talk before and you've always refused. The experience in New York with the tube was horrible. Of course the Do Not Resuscitate order you want is in your chart, but I'm asking you to think about it again."

"They told me if I went on it again, I'd die on it," Ms. V managed to get out.

"I know. But you've proved them wrong before. It's possible your lungs would fight the infection and then the tube would come out again." And you could live, Miriam thought, also thinking--charlatan! How could you tell her that? It's almost certain she'll die with or without the tube; her death with the tube will simply be more lingering.

But how can I just give up? Let her go? It's too awful. It's too--natural. She's too young. It's true she'd been unable to tolerate the newest, most effective medicines, and wasn't considered a candidate for lung transplant, but what if another treatment or option came out? And what if her judgment is addled by lack of oxygen?

"No tube," Ms. V squeezed out.

"We could make a plan." Miriam hugged her knees tighter. "We could try for a set amount of time, for example two days. Then, if you didn't improve, we could take the tube out and let nature take its course."

"No tube."

A rogue thought attacked Miriam. Cancel the Do Not Resuscitate order, Ms. V conks out from low oxygen to her brain, the team rushes in and does CPR, cardiopulmonary resuscitation, and intubates her while she's unresponsive. She'll wake up, know it was the right thing to do, get better, come to the office and we'll laugh about it. She'll be glad I did it.

Doctora Miriam knows best.

As her patient gasped for air, Miriam gasped at her retro-ethical idea.

How could I have such an awful thought? Am I a secret paternalist in autonomy clothing? What would Doug Allen say if he could read my mind?

Doug Allen was the chair of the ethics committee, of which Miriam was a member. This meant she got up abnormally early (in her opinion) one morning every few months to discuss and uphold principles such as autonomy, which gives all hospitalized patients of sound mind the right to choose a DNR order, as well as the right to accept or forego a sometimes daunting checklist of other medical options.

A meeting was planned for the following week, as a matter of fact.

Fantasy aside, Miriam knew her patient would be furious if anything was done against her wishes. She could even sue Miriam for battery—and likely would win, as most law suits relating to DNR orders involved resuscitating patients against their will, not for allowing them to die. Refusing to honor the DNR they wanted not only violated autonomy, but was even a third degree felony.

One of the things Miriam learned in the ethics committee was that most discussions ended up as a discussion of the law, moving quickly from "is it right?" to "can you get in trouble if you do or don't do it?" The lawyer on the committee usually had the last word in any debate, quoting from the health-related Florida Statutes.

But beyond both law and ethics was the inescapable fact that most doctors knew about DNR orders: when people reached the point of needing CPR, unless they were otherwise healthy and their condition stemmed from an accident, they were likely to die anyway. And if they didn't die, their quality of life was usually abysmal. Only in Hollywood does a dramatic chest-pumping scene have a happy ending most of the time. In reality, if you were that sick, statistically you were a goner either way--code or no code.

Maybe what we do doesn't matter that much, Miriam thought. JK had once said something like that to her. She remembered being surprised by the sentiment, and his tone, at the time. Miriam took a deep breath and bid her patient goodbye with a light touch on her arm.

She washed her hands slowly, wrote a note, and walked out of the unit, DNR order intact. Some people wanted to change the acronym to AND--allow natural death--which was probably a better way to look at it. But whatever you called it, she knew it was the right decision.

Still, how could you just sit back and let a patient like Ms. V go?