Worst Case

December 3, 2000

"She's basically decomposing in her bed" said the I.D. attending of the woman we had come to know as Ms. D. "I don’t think there’s much more we can do at this point."

The woman, now in her third week of coma and ventilator dependence after a massive stroke with pseudomonal pneumonia, renal failure, and fungemia, lay there with two closed , black eyes. Her long gray hair, seemingly the only part of her body that wasn't rotten, and yet, ironically, the only part that was technically dead, was neatly collected in a side-ways "pony-tail."

"Maybe someone should speak to the family about discontinuing the antibiotic therapy," said the attending.

"We spoke to the son yesterday," I answered. "We sat down in private with the service and renal attendings, and basically asked him to have mercy on this poor woman."

"And?"

"Well, according to him, she had once recovered from a condition worse than this one. He's hoping for a miracle."

"Ok then" said the attending , stopping just short of rolling her eyes, "continue the ampho."

Ms. D's son, himself older than my mother, was generally at the hospital promptly at 7:00am to check on our progress.

"How is the blood pressure?" he would always ask first thing in the morning.

"Pressure's O.K." I would respond and watch him rub his chin as if he could envision this woman's path back to humanity with perfect clarity...starting at 90/60. How I wished he had accidentally overheard the nephrologist's joke about "chi -chi" the day before. Maybe then he might have grasped the viciousness of his crime, a crime to which we were all now bound by duty to be accomplices. But I didn't have time to dwell on it as I had to deliver her blood-gas down to the lab myself , lest we get these "critical" data a few minutes too late. "What the hell does this woman have left to oxygenate?" I thought to myself as I headed toward the elevators. "The tending to the dead by the living: The ultimate waste of time."

A week later I sat at the nursing station grumbling to myself as I wrote my 20th note on Ms. D, when one of the more self-assured nurses took me to task:

"Why did you go into medicine of you hate it so much?" asked the nurse with just the right amount of self-righteousness.

"I always pictured myself using science to ease suffering," I answered, now trying to control my own blood pressure, "Not following some mindless set of protocols to prolong the death process. This woman should be terminally weaned."

At that point the nurse let me in on a little joke that was apparently popular in nursing circles:

"Do you know the difference between God and a doctor?" asked the nurse. "The difference is that God knows he's not a doctor."

"Jesus, what a crock of bullshit," I thought, or perhaps said, as the irony hit me, "The body wasn't designed to last long past the point that it could no longer breath," I said. "If anything, we were playing God when we put her on the vent in the first place."

"I'll grant you that." replied the nurse.

The next several days were more or less the same: Get blood-gases, adjust the vent, check the culture results to see what new, exotic, multi-resistant organism we had created in Ms. D's bloodstream by means of unnatural selection, and report it all to her son who wasn't worried as long as her blood pressure was good. Not that he didn't love his mother-of course he did-I just couldn't understand how two people could live in the same world, experience the Human Experience, and yet see things as differently as he and I did. Couldn't he see that this 80+ year old woman wasn't meant to be here any longer? Would I feel any differently if it were my mother laying there literally rotting in her bed? Christ, I hoped not.

One morning, I forget which, I went in to get the usual A.M. blood-gas on Ms. D and, after pressing my twice-gloved finger two inches into her edematous wrist, made a glorious discovery: there was apparently no pulse. "Could it be?" I thought, "That this debacle is finally over?" We checked the Doppler and sure enough, although her chest was still inflating and deflating artificially, Ms D's heart had stopped beating.

My disappointment at having to fill out a death packet when I had several other patients (hardly in better shape) to attend to quickly gave way to my sense of relief. No more chasing our own tails. No more feeling as though I was committing a crime against humanity. I noticed something else peculiar: most of the nursing staff were in a celebratory mood upon hearing the news. They, in their years of experience on the vile 7-W, knew that despite all of our efforts, the suffering had finally ended. How backward. And yet, although Ms. D had not displayed any of the qualities that define life in over a month, it still wasn't any easier for me to tell a man that his mother was dead. He had been so sure that blood pressure was life that I believe he was genuinely surprised to hear the news.

"I guess it's true what they say," I thought, "A little knowledge is a dangerous thing." So is a little humanity.