A Nurses Story | Chapter 25 of 27

Author: Tilda Shalof | Submitted by: Maria Garcia | 1443 Views | Add a Review

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Tracy bounded over to me as I was starting my day and she was coming to the end of her night shift. We didn’t work together as much any more because she’d had to change her schedule in order to accommodate the early-morning university classes she was taking.

“How can you possibly listen to a lecture now?” I asked, scanning her face for signs of fatigue. “You must be exhausted.”

“No, I’m not at all.” Her eyes were lively, but something was troubling her. “This course I’m taking has got me thinking. Do you remember Mr. Kerr’s death? I wanted to talk to you about how we could have done it differently.”

We all remembered the details about our patients, especially their deaths. Even when a patient died when we weren’t at work, we sought out the nurse who had been there, to tell us what had happened so that we could put it to rest in our minds.

“His death was terrible. The son was so upset with us. Remember how we left the tube in because we thought it would be too upsetting for the family to hear the sounds of his last breaths? But that just made it go on longer. We gave him morphine to make him look better and make the family feel better. The narcotic was for the family! They couldn’t bear to see anything that looked like he was struggling. Who were we serving?”

“I know.” I remembered this and much more. We had increased the rate of the morphine drip as the father gasped his last breaths, but even with morphine, he’d opened his eyes and looked around. Perhaps it seemed to the son that his father wanted to say something, but couldn’t. The mother was sobbing, the daughters were clinging to the mother, and the son was furious. “You promised he wouldn’t suffer,” he had cried.

“Sometimes it feels like we are orchestrating the whole process to make the families feel better. It doesn’t feel honest. We didn’t want to hasten it or prolong it, but remember how the family kept asking how much longer it would take? They wanted it over quickly and they assumed we could arrange that,” said Tracy, who suddenly did look weary. “Which we can, of course. They were shocked when I turned off the monitor, but we weren’t using it any more.”

We had all seen this reaction time and time again. Families rely on the monitor. They become so glued to it, sometimes for weeks, and then when the time comes and we pushed the “off” button, it is as if that is the moment of death.

“I know. They looked like my kids look at me when I turn off the TV and tell them to go to bed. It’s like they can’t believe I’d do this to them!”

We laughed uneasily.

“Mr. Kerr’s death has been haunting me,” said Tracy. “We didn’t handle it very well.”

I agreed. “The way a patient dies in the ICU is the nurse’s responsibility. Decisions are made – or not – in the family meeting, but in the end, the care of the dying patient is left to the nurse.”

I thought for a moment. “Trace, how would you have done that death differently?”

“I don’t know, but the son was so angry at us,” said Tracy. “I can’t stop thinking about it.”

“But the real reason the son was angry was that his father was dying.”

“I know,” she said and suddenly looked deflated. It was as if the fatigue, from having worked all night, suddenly occurred to her. I watched as she came to a halt, let down. But a second wind kicked in and she rallied to continue our debriefing.

“Then remember how afterwards we brought the family back in, as we always do, after we tidied him up, removed the IVS, tubes, and machines, and freshened the room. We made sure everything was nice and neat. We wanted to show them that he looked like himself again. Exactly how he would have looked if he’d died naturally. Sometimes, how we handle death feels dishonest.”

“I know,” I sighed.

“You know how sometimes we joke around afterwards?” Tracy continued. “I hate myself for it, but can’t seem to stop. Once I leaned over a corpse I was wrapping with another nurse to turn up the radio to catch a song I liked. I guess I had to make a disconnect with what I was really doing.”

“I know what you mean,” I said. “Just the other day, I was wrapping a body for the morgue and Morty was going on her tirade again about the shrouds and how they’re an occupational hazard. ‘Why do they make shrouds from this toxic plastic stuff?’ she was saying. You know how when we open them up they have that industrial chemical smell that we all try to avoid inhaling? ‘They’re going to make us sick,’ she says. ‘Why can’t they make biodegradable shrouds? You know, dust to dust. Eco-friendly shrouds! There’s a market for that!’ So, to the tune of ‘Born Free,’ she starts singing, ‘Die Green’!”

Oh, how we howled at things that were not the least bit funny, but the fleeting pleasure of the intoxication was rarely worth the queasy hangover of discomfort.

WE CLAIMED WE had seen everything, done everything. We were unshockable and unshakable. We boasted that nothing fazed us. We were seasoned veterans and felt confident that we could handle anything. After all, we’d dealt with the worst-case scenarios. We’d seen every drastic, catastrophic thing that could possibly happen to a human being. We were wrong. One day a patient rolled in that changed everything.

I received Mr. Bellissimo from the OR. He had cancer of the prostate that had spread to his bladder. But cancer was the least of his problems. He arrested on the floor and then developed a pulmonary embolism after a long cardiac resuscitation. Most troubling was the finding on the CT scan of his brain damage due to prolonged oxygen deprivation. However, nothing about any of that was unusual to us. We had seen other patients like him before; patients like him, and worse.

“We’ve managed to stabilize your father, right now,” I told his two grown-up daughters, Maria and Theresa, as I brought them into the ICU for the first time, “but he’s still critically ill.”

“Up on the floor, they worked on him for hours,” Maria, the older one, said. “But maybe, if they had gotten to him sooner, things would have been different?”

“I don’t know,” I said, “but sometimes it can be difficult to resuscitate a seventy-six-year-old heart.” WAIT, I wanted to warn them. Stop, for a minute. Don’t let us do all of this. If you let us, we’ll go too far and then it will be harder to stop than not to have started at all.

Mr. Bellissimo experienced no major crises or setbacks in the first few days, but even Dr. Huizinga and the surgeons looked uncharacteristically grim. They didn’t paint their usually optimistic picture to the family. I tried to be positive when I spoke to the daughters. After all, it was too soon to predict that a man this ill couldn’t get better, even though my intuition told me otherwise.

“We’re doing everything we can for him,” I assured his daughters, who were busy setting up camp in the waiting room, determined to stay for the duration.

For some reason, in case I might have thought otherwise, Maria said, “Dad’s a real fighter.”

“That’s good,” I said. “He will have a long road to recovery.”

“He loves to dance,” she said, and I was pleased she wanted me to know that about him.

“Bring in a picture of your dad, if you wish. We’ll put it up on the wall for everyone to see.”

“Unfortunately, he never danced with our mother,” I heard Theresa mutter.

“Mom died last year,” explained Maria, glaring at her sister to be quiet. “Dad lives with me.”

“How was he before he got sick?”

“Plays bocce ball every Saturday! Drinks a double espresso before bed every night.”

“Plus a grappa or two,” murmured Theresa.

“Dad has a great sense of humour,” Maria said and looked over at him with dutiful adoration. “Don’t you, Dad? Nurse, I’ll give you an example of just how funny he is.”

“When he’s sober,” interjected Theresa bitterly.

“If anyone ever asked Dad if he had any children, he used to say, no, but my wife has two.”

Maria shook her head in amazement at her father’s extraordinary wit.

A week later, Mr. Bellissimo developed an intestinal blockage and needed emergency surgery. Even Dr. Huizinga, famous for taking on challenges that no one else would touch, looked worried. When I came into the room to visit Morty, who was taking care of him that day, I found Daniel with his hands deep in the muck of the patient’s bleeding intestines. He took the patient back to the OR but when he returned he was still bleeding. We hung unit after unit of blood (we stopped counting at sixteen) and just as we pumped it into his veins, it oozed back out through his incision. Blood flowed onto the mattress, dripped down off the sides of the bed onto the floor. I went to get a mop.

“I’m going to bring the Red Cross in here so they can see where their precious resource is going!” Morty announced, looking down at her blood-splattered running shoes. “What a waste!”

Theresa was fidgety and tended to come and go while Maria was stalwart and sat in the room for most of the day, watching the cardiac monitor. I remembered Tracy’s comment and saw how Maria was watching the monitor exactly like it was a TV, with her eyes glued to her favourite program.

“I’m keeping an eye on Dad’s heart,” she explained when she noticed me watching her watching.

When I bent over him, to listen to his lungs and heart with my stethoscope, Maria regarded me as if I might, if I chose to do so, invoke the miracle they were praying for. The intensity of her gaze and the expectations it held, were unbearable because I had come to the realization that in her father’s case, I didn’t believe in what I was doing. Even worse, I had come to the conclusion that what we were doing was wrong, because it was causing suffering for no benefit.

“We’ve talked about it and decided we want to have everything done,” Theresa said when she joined her sister in the afternoon.

“Is it what your father would want?” I asked.

I decided not to wait for the family meeting to be called, arranged, and endured. I took the initiative to tell them what I knew. “It doesn’t look very good. The CT scan shows massive brain damage. He’s still critically ill. Have you thought at all about the possibility that he might not recover?”

“Yes, but that nice female doctor, you know, the pretty Chinese one? She said he might not recognize us. That he might get the words, but not know their meaning. That’s okay with us.” Maria spoke for them both. “We’ll take him like that.”

“Even before all this happened he sometimes thought it was 1950 and he was still in Italy,” said Theresa with a giggle.

Oh well, at least the war is over.

“She said it might be like he’ll be one of those people who see the golf club and the golf ball, but can’t bring the two together. That wouldn’t be so bad, would it?” Maria reasoned.

“That would describe a lot of beginning golfers,” said Theresa with a grin that looked to me, at that moment, positively goofy.

Two and a half weeks later Mr. Bellissimo was still there and the daughters chose to interpret his “survival” as evidence of his innate fighting spirit. However, their father was now full of a raging blood infection and pneumonia, too. We had him on three different inotropes at maximum doses to maintain his blood pressure, the systolic hovering only around 85.

“His X-ray looks like a snowstorm,” Nicole told me when I went in to cover for her break. “It’s a total white-out. Take a look at it. The daughters haven’t a clue how to interpret what they’ve been told about the CT scan of his brain,” she said. “They say it’s like if he’ll see a coffee cup, he might put his hand into the coffee, rather than grasp the handle. He’s got global cerebral hypoxia, for goodness’ sakes. He’s going to be in a vegetative state, if he even recovers from everything else wrong with him. Why doesn’t someone spell it out for them in terms they can understand?”

“Go for lunch,” I urged her.

Since Mr. Bellissimo couldn’t move by himself, we repositioned his body every few hours to make him comfortable. I called for Lola, the hospital assistant, to help me. At first she wasn’t paying attention, but all of a sudden I saw her eyes fill with tears as she looked down at the patient’s swollen face, ballooned out and straining tightly around the breathing tube, his black fingers and toes, his skin, dripping with infected sores.

“Your father, Lola. Where is he?” I asked.

“In Bosnia,” she said quietly.

“Sarajevo?” I asked because I didn’t know the name of any other city.

“No, Banja Luka,” she said. “This man is the same age as my father. I would hate to see my father like this. Why are they doing this to him? Don’t they see how cruel it is?”

“I don’t know.”

All the nurses were aware of Mr. Bellissimo’s case, and it was to his room that our gaze turned with mystified curiosity and incredulity when we arrived at the beginning of each shift. We were all checking to see if he was still there.

Another week passed and Mr. Bellissimo was still hanging on, after yet another cardiac arrest and a few more complicated setbacks: infections, intestinal obstructions, and more organ failure.

Morty called in the night before a shift and requested to be his nurse the next day.

“I’ve decided what I’m going to do,” Morty told us when she came in. She was wearing her “No Whining” sweatshirt and dangling earrings in the shape of tiny inukshuks. There was a determined, devilish look in her eye that I had never seen before. I decided to keep a close watch on her.

On rounds, Dr. Huizinga put forth a pathetic case for continuing treatment.

“What I mean to say,” he said and pushed his glasses up to his head so that he could rub his eyes, “is that I am attempting to determine the extent to which, by that I mean the extent to which I, and hopefully in conjunction with Mr. Bellissimo’s daughters that is, but this may or may not be the case, and with all due respect to Dr. Dejenni,” he gave a deferential glance to a visiting colleague, “who’s come here at my request to offer a second opinion – notwithstanding the hospital’s exorbitant parking fees …”

“He’s floundering,” I said, embarrassed for him.

“What a ditherer!” exclaimed Nicole in astonishment.

“He’s a coward.” Laura was disgusted.

Yet we were all so fond of him. We knew he was kind and caring, and a brilliant and daring doctor.

“He’s an idiot,” Morty blurted out.

Daniel overheard her and looked crushed.

“Go apologize to him, right now,” I told her. “You’ve hurt his feelings.”

“No way.” She folded her arms across her chest.

“Justine, I have a sense you’re in disagreement with the treatment plan,” Dr. Huizinga said.

“Don’t you disagree, too? Be honest, Danny! You can’t even defend what we’re doing. You can’t even come up with a convincing case for it.”

“No. I have to admit …” He hung his head. “We are bound by the family’s wishes. Say, are they perhaps motivated by religious beliefs?” he speculated. “Are they Catholic?”

“If these people are in any way religious,” said Morty, glaring at him, “their father is in purgatory.”

Later, Morty read out loud to all of us gathered at the nursing station the note that Dr. Huizinga had scribbled in the patient’s chart:

“‘The severity of the situation was explained, along with the possible limitations of escalating treatment. My view is that his survival is not guaranteed and the most likely outcome is non-survival.’”

“Non-survival! Isn’t that the richest euphemism you’ve ever heard?” Morty said. “What bullshit! This is the crap he writes on a patient who is practically dead?”

No one rose to her bait. We’d heard it all before, so many times, and we needed a break from talking about it, thinking about it, and most of all, from doing it day and night. The hundreds of versions of this same conversation had finally left us exhausted.

As soon as the daughters walked in the door later that morning, Morty was ready for them.

“Maria. Theresa. Today I’m going to answer all your questions. I will tell you everything you want to know. Would you like to see what we’re doing to your father? Good. Here goes.” She grabbed the curtain, pulled it around the bed, and flung off the blankets that had been covering their father. Morty stripped back his gown and showed them his bloated body, the mottled limbs, the necrotic fingers and toes, wrinkled and black as prunes.

“Dead tissue,” she said.

The sickening smell of his exposed, rotting body quickly filled the room.

“These fingers and toes will fall off, any day now,” she said evenly. “These too,” she said as she showed them his testicles, the size of two bulging cantaloupes. She pointed out how they were leaking rivulets of clear yellow fluid all over the soaked, folded towels upon which they had been propped. She allowed them to register these sights for a few minutes.

I kept my eyes on the daughters’ horrified faces and took a mental note of where the chairs were in case I had to catch them if they fainted.

“I’m now going to suction the secretions out of his lungs,” said Morty, evenly.

They watched him strain and cough and choke as she pushed the plastic catheter into his lungs and then as it sucked out strings and clumps of green sputum. Morty suctioned his black mouth, which was full of sores and blood clots.

As she prepared to clean around his tracheostomy with swabs dipped in hydrogen peroxide, something caught Morty’s eye. She looked down, leaned closer, and what she saw there made her reel back in horror. With a pair of tweezers she picked out two long white wriggling things.

“Maggots!” She gagged and dropped them on the floor.

I retched, too, and looked about for a garbage can I thought for a moment I might need.

“Maggots fester in dead tissue!” she practically shouted at them as the two daughters ran out, sobbing.

“This is a corpse. I have never been so disgusted in my whole life.” Morty peeled off her gloves and threw them in the garbage. We both went over to the sink to wash our hands.

We went outside the room to get as far away as allowed and possible from the situation.

“A corpse doesn’t disgust me, but nursing a corpse does,” she said. It was the first time I had ever heard her voice go quiet.

“If he was really a corpse, I wouldn’t feel as bad, but he’s a living human being that we are heaping this indignity upon,” I said. “Who knows what he’s feeling?”

“They treat prisoners of war better than this,” Morty said.

“We’re torturing him, whether he feels it or not.”

ARE YOU SUGGESTING that our treatment of Mr. Bellissimo is futile?” Dr. David Bristol asked me on rounds when he heard my complaints.

“Please don’t put words into my mouth,” I said. “I didn’t say that.”

“You – and many of the nurses – have been implying it.”

“Okay, yes, I’ll say it. What we are doing is futile.” It felt so strange to say that word. It was a word I’d never said before. I’d never tasted it in my mouth before. It was so concentrated and bitter.

How could I do this work if I thought any of it futile?

“Futility.” David spat out the word. “Can you define it for us?”

He waited and the team listened closely with him.

He’d trapped me into doing something that was against my nature. Futility meant there was no hope, and if nursing had taught me anything, it was that there was always reason to hope. If one knew what to hope for. Not always hope for a cure or a complete recovery, but hope for peace, comfort, and dignity.

“Futility? I can’t define it exactly, but I know it when I see it,” I said lamely.

“That’s not good enough,” he said, amused at my discomfort. “Give me proof.”

“It seems to me, David, that we’re being devious here. Families see all the technology we have to offer and they want to believe it can help their loved one, too. They don’t know enough to decide whether or not it is warranted. They don’t want to have to make those decisions themselves. Who can blame them? We all know that someone of Mr. Bellissimo’s age who has this many serious medical problems cannot survive. Yet we act as if it’s a possibility. We expect the family to help us choose – do they want inotropes? Compressions? Dialysis? Shocks? All of the above? We make it like a Chinese menu – one from column A, one from column B, and they have to place the order all by themselves.”

“No sub-sta-too-shuns,” said Morty, but for once, her interjection didn’t break the tension.

“And,” I said, “we’re not doing enough to interpret these situations for families so that they understand the implications of their decisions. The public is informed by pop culture, television, and sensational stories in the press. People hear about miracles cures, overnight recoveries, and unexpected successes. They have no idea what’s really in store for them when they come here and they’re in no state to make rational decisions. They’re worried that someone will accuse them of not doing the right thing or they worry that they won’t be able to live with themselves afterwards. Their decisions are based on fears of possible regret. The responsibility is too much for them to bear.”

I stood there recalling another discussion on the subject of futility. It was a terrible argument I’d had once with my husband, the most positive, optimistic person I know. I told him how angry I was and how I had tried so hard to get along with him, but that it was no use.

“I have tried and tried to communicate with you,” I said. “I can’t try any more.”

“There can never be enough trying,” he yelled back at me.

As angry as I was – and, thankfully, we eventually made up – even in those heated moments, how I loved his hope, in the face of my temporary loss of faith.

“Tilda, if you can’t handle this situation, I suggest you not take care of this patient.”

“David, you’re right. I can’t handle the situation. Do you want to know why? Because what we’re doing to Mr. Bellissimo is wrong.”

Most doctors just couldn’t make the switch. To them, even an artificial semblance of life was preferable to what they saw as the worst possible outcome, the failure of all their efforts: death. Something preventable, diagnosable, or treatable must have been missed. Perhaps it was born out of a fear that some family member would come forward and accuse them of an oversight, or of not trying hard enough. But perhaps because of our immediate, first-hand proximity to our patients’ suffering, most nurses felt differently.

“When it comes to doing deaths, you guys are like Wayne Gretzky trying to figure skate!” said Morty and finally managed to get a weak semblance of the reaction she wanted out of them.

THE FOLLOWING WEEK, Dr. Huizinga was the attending staff physician, and he was the next to have to face an unruly insurgence of the rabble. We accosted him with our outrage and indignation.

“Talk to the daughters about withdrawing treatment!”

“Enough is enough!”

“It’s time to let nature take its course!”

“We’ve gone too far this time!”

“It’s refreshing to hear the nurses’ perspectives,” he said, stepping back from us. “Frankly, it’s one I’ve tended not to pay much attention to. A physician has to be optimistic. It’s difficult to be the bearer of bad news. Perhaps we avoid these conversations with patients because of our own discomfort. Perhaps we don’t take the time to explain everything thoroughly.”

“We lead people to believe that we can cure everything,” I said.

“You’re probably right,” he conceded unhappily. “Ah, medicine is an art, but patients expect doctors to be scientists and know everything,” he said.

Spoken like a true scientist.

Later that day, Mr. Bellissimo’s daughters came to me with a suggestion.

“If Dad’s brain is damaged, could he have a brain transplant?” Their eyes were bright.

I looked at them, stunned. I didn’t say anything. I didn’t know where to begin.

“And another thing,” said Maria, “my daughter read on the Internet that breast milk can help people fight infections.”

“What?” Were they prepared to offer some?

“Yes,” she said, “breast milk boosts immunity.”

“Where are you going to get … it?” I inquired.

“Isn’t there a maternity ward in this hospital?”

“No, there isn’t any more.” It was true. Our “general” hospital had become so specialized that something normal like the birth of a baby or even the routine removal of an inflamed appendix was not performed. “There is no maternity ward here,” I said unhelpfully.

“You think because he has cancer that he’s a lost cause,” Maria said to me as a warning. “Don’t give up on him so easily. He’ll surprise you.”

THE BELLISSIMO CASE made me recall a patient I’d once taken care of who was a survivor of Auschwitz. I needed to insert an IV and the best vein I could find was a beautiful thick one running right through the concentration camp number tattoo on her arm. Perhaps this place now will give life, not remind her of near death and total evil, I rationalized, as I slid the angiocath into the compliant vein and received my reward of the red flashback of blood to tell me that I was in the vein.

I couldn’t help myself but ask the husband to tell me about what his wife had been through.

“They called her Christine,” he said. “They changed her name from Esther and hid her. She was lucky one, see? Blond and blue eyes. But they found her and sent her to the camp.”

“Which is worse,” I had to ask, “this or that?” I shuddered.

“That,” he said without hesitation and stared at me, unblinking.

Together, we took a look over at her. Her hands, contracted into hardened claws, scraped at the air as if trying to escape. Her face was frozen into an anguished, contorted grimace.

“She survived that horror … hasn’t she been through enough?” I guess I gave myself a certain licence to be familiar in this case, to push my questions past a barrier I had never crossed before.

“She survived that, she’ll survive this.” He sat down to read a Yiddish newspaper, one that looked like it had survived the war, too.

BETWEEN THE TWO of them, Mr. Bellissimo’s daughters kept up the round-the-clock vigil. However, eventually Theresa had to return to her family and work, but Maria was there when I came in one morning. I encouraged her to tell me about her father. I listened to how he had tried in vain to persuade her daughter not to marry a boy from Trinidad and how he had loved the delicious lasagna she made. Maria trimmed his beard, smoothed the blankets, and exchanged the blue one for the yellow one. She rubbed his feet and put mineral oil on them.

“We’re not religious,” she explained, “but we were brought up Catholic, taught to respect our father – even if he doesn’t exactly respect us.”

“What do you mean?”

“He’s a tough son of a – excuse me. He’s very … strict.” She pursed her lips. “Anyway, we’re hoping for the best, but trying to be realistic.”

“Do you understand the situation?” I asked.

“Yes, but we believe he’ll make it. I asked Dr. Bristol if there was any chance he’d make it and he said that there’s less than 1 per cent chance. But even if that’s the case, we’re willing to take it. All we’re asking for is a 100 per cent effort. It’s worth it for a human being, don’t you agree?” She pulled a Blue Jays baseball cap out of a plastic bag she’d brought with her and then a Maple Leafs cap and put one on either side of her father’s swollen head. Diagonally across his body, she draped a banner that said Forza d’Italia in red, green and white.

REMEMBER JOAN HOUSLEY? Why can’t more families be like hers?” the nurses asked one another.

When they realized that a cure for their mother’s advanced cancer was not possible, Mrs. Housley’s husband, Jim, along with their three daughters, Jill, Janet, and Jenny, all agreed when I suggested we turn off the cardiac monitor and focus our attention on her comfort and dignity, on Joan herself. But I had had to make my case before the team, beforehand.

“It’s not as if we’re going to treat an arrhythmia, are we? We’re not going to do CPR, right?” I argued. I saw Daniel considering this radical move I was suggesting. “I’ve heard you say it yourself, Danny, ‘Don’t do a test unless you’re prepared to treat the results.’”

I saw how difficult it was for him to shift his thinking, how hard he had to work to restrain himself, to do nothing and not feel the ensuing sense of defeat.

The night Joan did arrest, Tracy and Nicole sat with her until her family arrived. The resident on that night was young and hesitant. He hadn’t got to know her as we had.

“Don’t you think we should give it a try?” he said. “Just one round of CPR?

“No. We know her wishes.” I stood firm. “She told us, herself.”

“But no one documented it,” he whined.

“Trust me,” I said.

After six weeks, the Bellissimo daughters hardly visited any more. Even Maria called only occasionally or sent a fax of her questions or suggestions. A lone granddaughter came a few times.

“He’s leaking on me,” she said, holding up her scarf to show me.

“His skin is falling off,” I said. “It happens when the person is …” Dead, I wanted to say … “Terribly sick.”

“What would happen,” she ventured – and I knew exactly what she was going to ask – “if everything were turned off?”

She wouldn’t dare ask this question if her mother were there, so I answered quickly, in case she arrived. “Your grandfather’s condition is so fragile, so close to death, that if even one thing was turned off, or turned down even a little, like this oxygen dial,” I pointed to it and circled my fingers around it gingerly, “he would probably die in a few minutes.”

The nurses charted extra-carefully. Not only the fluids in and out, numbers up and down, but also what was done and not done, what was said, and not said.

“Defensive documentation,” our nurse manager advised us.

“A family meeting,” I said to the granddaughter in a staccato short form that this desperate situation seemed to warrant. “We need one.”

“My mother and my aunt Theresa don’t want any more meetings,” she said.

“Not a big meeting, a little one, here in the room. Not in the quiet room. Not sitting down, standing up. A short talk, here in the room.”

The daughters had been eluding us. They had stopped answering the phone or returning our messages. One day they sent a fax with a series of requests, including one that their father was to be treated only by senior staff physicians, no residents or interns. The room was to be kept at precisely 22°C. There were to be no cool drafts or glaring lights. They requested that only “the cheerful nurses” be assigned to their father’s care. “We do not want people with negative thoughts caring for our father.”

On the day when Mr. Bellissimo’s heart rate slowed to a sluggish 50 beats a minute and the few drops of urine that he put out were black and full of sludge, Dr. Leung was the attending staff physician and I was the nurse in charge.

After all these years, three children, numerous scientific research studies, and hundreds of academic papers, Jessica showed no signs of aging. She was still so beautiful.

“I guess we’ll have to offer them dialysis,” she said firmly, but I saw by her averted eyes that she was not exactly at one with this additional intervention herself.

“But Jessica,” I said, “what will we gain by offering dialysis?”

“The daughters are representing his wishes. These are his wishes.” She shrugged her shoulders as she added, “Apparently.”

“But they’re not acting in his best interests! They’re not rational.”

“I have spoken with them at length, and I’m convinced they believe this is what their father would have wanted. It would be presumptuous and arrogant of us to move to a paternalistic approach and assume we know what is best for patients. Not only that, but in this case it could become highly adversarial.” She sighed wearily. “Tilda, think about the situation it puts us in if we override them. You have to understand where we, the doctors, are coming from.”

She saw my skeptical expression. I could feel it on my face.

“I don’t know!” She held up her hands. “We don’t have all the answers.”

“No, but neither do the daughters and they’re making bad choices,” I said. “How can we protect the father from his daughters’ bad choices?”

“Tilda, you presume that you know what’s best for him, even better than his own family?”

“Jessica, this poor man is rotting in the bed. I’m merely stating the obvious! It’s common sense!”

“How can you know for sure that Mr. Bellissimo wouldn’t want this done?”

“Do you know anyone who would?”

Jessica took a deep breath and composed herself.

“The thing I value the most, the thing that is most important to me in my practice is to be completely transparent and honest in everything that I do. Constitutionally, I am not able to tell a lie. That is who I am, and the day that changes is the day I get out of this profession. It is our duty to carry out the patient’s wishes. Therefore, I have no qualms about this situation. I’m here, along with the nurses, to support the decisions the family has made. Let me remind you, Tilda, that we are not here to pass judgment. This is our job, whether I agree with the family or not. It is not about our beliefs, it is about the patient’s beliefs.”

Then it was my turn, and Jessica listened to me with equal patience and respect.

“To me, Jessica, the thing I value most, the thing that is most important to me in my practice is kindness. Nothing is more important to me than doing work that is kind. That’s why I’m having such a difficult time with this case. It is cruel.”

“This is not an assault and battery. Let’s remember that,” she said, bristling slightly at my intimation that she would be a part of anything that was cruel. “We are all motivated here by a desire to do good. Please keep that in mind, Tilda.”

“Yes, but what we’re doing isn’t benevolent. Anyone can see that …” I was losing steam.

“How would you handle it then?” she asked. “Pretend it’s you now, Dr. Shalof.”

“I wouldn’t offer one more medical intervention, certainly not dialysis or CPR in the event of another cardiac arrest. I would immediately insist on withdrawal of treatment and turn the focus over to comfort of the patient and support of the family. I would bring in second, third, fourth opinions, for the professional corroboration. I would bring in legal advisors, if necessary. A judge. A court injunction. An appointed guardian.”

“All that could take weeks in itself,” she said, smiling at my simple-mindedness. “In the meanwhile, we’re not harming him.”

“Oh, yes, we are,” I said. “I guess it’s different for the nurses than for the doctors. We’re right there with patients, minute by minute, day and night. We do these things to the patients. We see them in the state they’re in. We see the family’s suffering and how we are prolonging it. The doctors come and go. Have you seen how Mr. Bellissimo’s skin is all dripping, open sores? Have you watched how he grimaces in pain with whatever we do to him?

We keep giving him little boosts of epinephrine to keep him going all day. We can’t even give him much morphine because it drops his pressure too much.”

“I hope you don’t feel, Tilda, that my word prevails over yours,” Jessica said.

I knew she was trying to be conciliatory and draw this unsettling conversation to a peaceful close. She didn’t need to do that. She and I had become friends as well as colleagues, and I had grown to love and respect her. We had worked together for years. I remembered when she started out as a resident, then as a senior fellow, and I was such a neophyte nurse, just trying to keep up with the basics. Our argument was not personal or acrimonious, even though it was vociferous and emotional.

“We are a team,” she insisted.

“Yeah, but why do the daughters prevail?” I could hear myself whining like a child.

“They’re the next of kin. You know the law, Tilda. I am simply following the law.”

“The law cares nothing about compassion or the dignity of real people! We’re making him into a freak, and allowing him to become grotesque. What we are doing has no purpose other than to mollify the daughters, to avoid confrontation, possibly even litigation –”

Laura came over to us, carrying something in her hand.

“How did you know there could be a lawsuit, Tilda? One of the daughters just sent this fax. It says her father deteriorated while under your care yesterday, and she thinks you caused it. She’s threatening to bring in a lawyer to review the chart. She’s got it in for you, baby!”

“That’s fine. I have nothing to hide.”

“Are you on a mutiny?” Laura looked amused. “You know you’re becoming a drama queen.”

“No,” I answered, “I’m refusing to take care of this patient. I am a conscientious objector, a peace activist, and a front-line soldier. I’m going on a work-to-rule campaign.”

That was that. For now.

IF YOU GUYS are going to talk about Mr. B., I’m leaving,” Laura said after work that evening. We were in a bar near the hospital, having drinks. “I don’t want to hear another word about that case.”

“No. There’s nothing to talk about. I simply refuse to take care of him,” I said.

“Are you on strike?”

“Kind of.” I knew I wouldn’t last.

“You won’t last,” Laura said.

“There’s no way I’m going in there again either,” said Tracy. “I’m with you, Tilda.”

“Every human being deserves nursing care,” said Frances. “I don’t like it either, but I’ll take care of him. I agree with Jessica Leung. It’s our duty to carry out people’s wishes. As nurses, we can’t just give up on a person because we have a disagreement with the family. We have to put our personal opinions aside and do what is right for the patient.”

I decided to boldly take the lead with an idea I had been cooking up, privately. I was ready to spring it on them. “Listen guys,” I said. “I’ve figured out what we have to do to make sure this never happens to any of us.”

“I thought we said we weren’t going to talk about work!” protested Laura.

“I’ve been thinking of getting a tattoo on my chest that says ‘Do Not Resuscitate,’” said Nicole. “After this case of Mr. B.’s, I’m not taking any chances. When the time comes, who knows what my family will do with me? Oh yeah, and one more request, make sure Murry takes care of me. I know he’ll pluck my chin hairs and touch up my grey roots before my family comes to visit.”

We all knew she took her mortality more seriously than her light-hearted words indicated. For some time we’d all known that Nicole had been preparing photo albums and storing away treasured keepsakes for the children whose names she’d already picked out and whom she hoped to have one day. Frances sipped her beer quietly. After all, it wasn’t the first time we’d had one of these apocalyptic conversations.

“Dump my carcass in a garbage can,” Morty said. “I don’t believe in graves or funerals and I certainly don’t want my liver going to some drugged-out alcoholic.”

“We have to draw up living wills, decide on our advance directives, and write everything down,” said Tracy. “We have to make our wishes known. Sign our donor cards. What else is there to do?”

“I’ll tell you what I’m proposing,” I said. “A pact. We’ll appoint each other – our group – to be the decision makers for one another if any of us gets critically ill. We’ll communicate clearly to one another what we want done in various scenarios – make our wishes known – as well as putting it in writing. We can’t leave these decisions to our family. They won’t know what to do. Who would know better what to do than us? Who’s in on this with me?”

“What about the last remaining one?” asked Morty, thinking this over.

“I don’t know, I guess she’ll be on her own. I haven’t worked out all the details, yet.”

We fell silent. We’d had enough talk of death. But it was something worth considering, they conceded. Perhaps some other time, on another day. On another occasion. Not now.


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Great book, nicely written and thank you BooksVooks for uploading

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