Comfort Zone

Chapter 38

The second ethics consult came later that day. Dr. Rochelle Berman, an internist Miriam knew from a few brief interactions over Danish in the doctors' lounge—they both agreed the cheese was superior—called her on her cell.

"Miriam? Got your number from Edna. You're our ethics maven this month?"

"Good," she said, when Miriam concurred. "We need your help, and Edna's—she's a trip, isn't she?—I see we agree on more than Danish. Anyway, help us pull the plug. My patient needs to go and his surrogate won't let him!"

Miriam met Rochelle and her medical student Rebecca at the ICU bedside and heard the details. Thomas Lerner, eighty-five years old, admitted four months previously for hemorrhagic stroke, a big bleed in the brain. Never woke up. One typical complication after the other. First pneumonia, and C-difficile diarrhea caused by the antibiotics for the pneumonia. Dehydration from the diarrhea shot his kidneys and dialysis was started. Then he got an infection from the dialysis catheter and was on more antibiotics which shot his liver. Then he got a blood clot in his leg because he wasn't on blood thinners because of the bleed in his brain, and they put in a filter to stop it from going to his lungs but somewhere along the line he had a heart attack and needed to be intubated. Then the delicate skin on his buttocks started to break down. Then—

"Stop!" Miriam said. "I can't stand it and I'm a doctor. I get it."

"We both know tons of health care dollars are spent in the last six months or so of life, and a lot of it is no good for the patient! This guy is a poster child for health care reform that will never happen. I didn't personally know him—he's a patient of one of my partners who works mainly down south now—but I would guess he'd want to throw in the towel if he knew what was happening to him. If he'd taken the time to fill out a living will, we'd know for sure, but he didn't. Anyway, things are grim, but we can of course keep him going, if you can call it that, for who knows how long."

"He's not going to recover brain function?"

"Two independent neurologists say it's as likely as an increase in Medicare reimbursement. Persistent vegetative state, now becoming permanent. Shades of Schiavo"

"Schiavo?" Rebecca piped up. Miriam had nearly forgotten she was there, but now turned to answer her.

"Terri Schiavo, the case that mesmerized Florida for years until she died in 2005. In 1990 she had a cardiac arrest and entered a vegetative state, which is also called 'eye-opened unconsciousness.' That's when the person breathes, digests, and performs basic functions that keep the body alive, plus the eyes and limbs move and they appear awake. To the hopeful observer, it appears their loved one is paying attention and trying to communicate.

"But it's not so. On objective exam, there's no evidence of function in the upper brain, the part of the brain responsible for awareness and understanding. In short, the things most of us believe are crucial for personhood and a good quality of life."

"Can they wake up?"

"Yes, but like other comatose states, the longer they stay in a vegetative state, the less likelihood of it happening. After three months, the state is deemed permanent, though there's still a remote possibility that the person might regain consciousness. It's this tiny, usually false hope that keeps families and the medical team treating them aggressively."

"This man had been unresponsive for a full four months," said Rochelle, "Plus his organs are failing. It's clear to all the medical staff that he's outlived his body. But I can't even get a DNR from the surrogate, let alone the OK to extubate him or stop dialysis. If his heart stops, we're going for a slow code. What does the ethics committee say about that?"