Comfort Zone

Chapter 22

It was already late by the time Miriam finished the orders, admission note, and her discussion with the nurse (noting his glazed look at her over-cautious instructions), but she had one more task to do: printing out an Ethical Consult Request Form to be used if Lilly Fielding failed to wake up.

Name of patient. Date. Those were easy, but the next question was trickier.

Person Requesting Consult. Dr. Tatiana Powell, she imagined writing in the space. She certainly couldn't write Miriam Gotlin because it was patently unethical (not to say ludicrous) to do a consult on one's own patient. But it couldn't hurt to wear the ethics cap for the weekend, she told herself, and think clearly through the issues. Edna would have to do the real job, or Doug would have to assign someone else. Obviously.

Summary of Medical Conditions. Miriam silently presented the case. Eighty year old woman with syncope in supermarket, found to be bradycardic and hypotensive. Temporary pacer placed in ER. Comatose after incident. Work-up in progress.

She pictured the patient hefting some watermelons in the supermarket, getting dizzy from her decelerating heart beat and passing out, only to be revived moments later by one of those young, hunky paramedics.

Is the patient capable of making health care decisions? Nope. But any minute she could wake up rested and refreshed, wondering what all the hubbub is about.

Does the patient have advance directives, i.e. a living will or DNR order? Not that I can find. Maybe hidden away in Tati's office under the mess.

Is a designated decision maker (surrogate) documented and available? Unfortunately yes.

Ethical Issues. Autonomy, informed consent, surrogacy.

The Fielding mess, as Miriam already thought of it, centered on the surrogate. Marilyn's role was to give so-called substituted judgment: to speak for her mother. As surrogate, her job was to tell the medical team what her mother would want, and not what Marilyn wanted for her. It was an awesome duty. But as Miriam had implied to Richard Quest, families made mistakes all the time. How well do we really know each other, even those we love the most? Miriam thought of all the things she'd heard families say.

"He'd never want to live like that. Dad couldn't stand any weakness in himself or others."

"Mom will break down if she hears she has cancer; we've always shielded her from bad news."

"Let my sister go without knowing she's dying, let her believe she getting better. It's what she would want."

But it turns out that Dad wants to live despite his deficits, and Mom already knows the truth! She's known every bit of bad news that was kept from her for half a century, and it hasn't killed her yet. She's been the rock in the family, but no one knew. As for the sister, she wants to know the end is near so she can tie up loose ends, make amends, say goodbye and I love you, and burn all her old diaries.

We just don't know, Miriam thought. We don't know our families, we don't even know ourselves and how strong and resilient we can be, how able to cope.

I never even thought I could cope with my divorce, and living by myself. But here I am.

Reason for consult. Was there even one? Yes, there was. Doug Allen's voice echoed in her head, asking the crucial question.

"Is the surrogate willing and able, and, most important, does he or she have the wishes and well-being of the patient in mind?

"Or is there another agenda?"

That was the problem in a nutshell. Miriam wasn't at all sure.

She knew the effect of worry and stress, and how they could turn a nice person unrecognizable. Miriam had trained herself to pierce through this veneer, but now found herself unable to overcome her prejudice of the daughter. I just don't trust her, she thought. Maybe I'm prejudiced because of the way she looked at my sneakers and turned up her nose, or...her power. She acted like someone who never apologized or explained. But more importantly, she didn't even touch her mother. Not a single caress, not a single cry of "Mom! Wake up!"

But maybe I'm wrong, and her daughter and the CEO are right, she thought. Maybe she'll wake up and refuse the pacemaker after all.

Miriam sat back and thought about Ms. V.

Maria.

She'd had to stand by and let Maria go when a tube could have prolonged her life. Her life? Miriam immediately realized her error. With Ms. V's bad lungs, she would never have gotten off the ventilator; it would only have prolonged her death. Ms. V knew exactly what was ahead of her: a painful, messy, lingering end, and she'd made the only rational decision.

But there were plenty of examples of doctors being forced to stand by when patients made decisions that seemed, frankly, awful. "It's the patient's right to be unreasonable," the ethics chairman always said.

Every doctor knew about a Jehovah's Witness who chose to bleed to death rather than accept a transfusion. A few small bags of blood might save their life, but they said no.

But this wasn't a matter of religious belief. Just look at this not-so-old lady Fielding, Miriam thought, embarrassed to find her eyes welling up. She wears lace undies and paints her nails red. Miriam couldn't believe that the woman she'd seen on the gurney was ready to check out if a small box implanted under the muscle of her upper chest could prevent it. Her daughter admitted she had a great life. Why not extend it?

Death made her think about the pharmacy technician George, cut down prematurely, and then about her missing colleague. Was JK dead, too?

Maybe the cardiologist has already convinced Marilyn. Stop these morbid thoughts and go home!

Instead, she sat eavesdropping as two nurses chatted in the break room about the time JK stole Anabelle's shoes. Anabelle was a nurse's aide with an unfortunate high-pitched voice and a tendency to zone out. She was frequently overlooked.

"Remember her squeaking 'Do you see my shoes?' to everyone who walked by? 'Teach you to take them off,' I told her. Finally Eva got tired of Anabelle's moaning and turned to JK who was sitting at a computer doing his computer work. Botwork, like he always called it, but for once he was quiet—sure sign something was up. Eva said, 'John Keating Barlow, you big lug! Will you please give Anabelle her shoes back?' Remember how he looked up at her all innocence? Before taking her shoes out of his pockets of course!"

"He was such a tease. The way he knelt down in front of her and put the shoes on her feet...like she was Cinderella!"

"You know, I always thought that was the real reason he did it. To make her feel like a princess."

"What do you think about the rumors, about him stealing drugs?"

"Not JK! He would never take pain medicine from someone who needed it. No way!"

"That's what I think too, but I did hear they have proof that he swiped into the surgical suite at the right time."

"Must be a coincidence. He must have been checking on a patient going for an operation. He always did that."

"Where do you think he is, anyway?"

"No friggin idea."

Miriam took one last look at the final line of the ethics form.

Recommendations. No friggin idea. She tossed the form aside and went into the room to visit Ms. Fielding once more before going home. She looked like a cool lady asleep. Awake she was probably as brash and obnoxious as her daughter. She looked down and wondered--sweet old lady or gray panther?

She wanted to find out. She wished Tatiana would call her, come home early because the mosquitoes were devouring her.

Lilly Fielding! Wake up!