Contact Precautions April 17, 2009

I don’t know how many times my mom was admitted to the ICU that month. Ten? Twenty? By the end of the second week, I had lost count. Occasionally she was transferred upstairs, to a “regular” in-patient unit, but that never settled my queasy belly. I knew I’d see her again the next day, a tube down her throat once more. I was told that it was helping her breathe, but really it looked more like a white plastic parasite pulling out her entrails. As a mere medical student, I felt like a child, her youngest son, helpless to do anything to save her. Sometimes she was admitted twice in the same day, and sometimes she died. It was never easy for me to witness, but I suppose it was much worse for the other members of the family – her blood family. Whereas I was just imagining my own mother in the hospital bed, hoping that her health would never fail her in this way, these people had to stomach the reality of their loved one sick, suffering, and dying. For the families and medical staff alike, every day was the same: hoping for the best, preparing for the worst, and never quite sure what to say to one another.

Worried “what if’s” swirling in my head, I would go about my work as a distraction, transcribing lab results or punting medical questions to my senior residents. During the afternoon, when my charting and procedures had been completed, I would sit and watch these family dynamics from the relative safety of the nurses’ workstation. Turning to each of the twelve rooms was like flipping the channel between twelve different soap operas, sitcoms, and “reality” shows, all playing out simultaneously. I tried to pay close attention, knowing that the next morning at sign-out we’d be critiquing each episode, like workplace gossip around the water cooler. In our discussions, sometimes we’d use names, but other times, just numbers.

“Room 14 keeps changing her mind about getting a trach,” one of the residents said one morning, between bites of a donut. “Whenever she decides she doesn’t want it, her family yells at her until she relents. She has stage IV metastatic ovarian cancer. Don’t they realize she’s a candidate for hospice care, not surgery?” I had seen this episode before: it was a rerun of “Father Knows Best.” I found it ironic that we, her medical family, were trying to impose our will upon the patient, just as her blood family had been doing. Did they understand her prognosis? Were we telling her to give up hope? Could the cliché of “dying with dignity” also mean dying on her own terms, fighting against the cancer until her very last breath? Under the supervision of the residents, each intern and medical student had taken ownership of two or three patients. Room 14 belonged to someone else, and so I kept these questions to myself.

If sometimes paternal medicine got the best of us, other times, we weren’t sure what to do. “I spent nearly 30 minutes on the phone with Mr. A’s son yesterday. He has Power of Attorney but clearly doesn’t understand what that means,” one of the other residents began, shuffling his notes. “He kept trying to get me to talk to his wife instead, but of course legally she can’t make any decisions.” Mr. A was one of my charges, and the biggest ethical challenge I had had to date. I had helped the resident admit him a few nights ago, when he had presented to the emergency room with delirium and profound anemia secondary to a large gastrointestinal bleed. After we resuscitated him with blood and fluid, we asked his son to temporarily suspend his “do not intubate” order so an upper endoscopy could be performed. In the period between changing the order and his scheduled procedure, Mr. A decompensated and, with no order to stop it, we had to intubate him for respiratory failure. Now we had become social workers and lawyers, arguing whether this was a “terminal state” and whether we should ask the son to have him extubated. “We should get an ethics consult,” I spoke up, breaking the fourth wall of this medical soap opera. “I don’t think this is what he wanted.” (How could I say that, having known Mr. A for only a few days, and never when he was conscious?) One of the senior staff shot me an angry look, and I closed my mouth. The decision was made to do nothing, and soon the team had moved on to talking about the next patient.

In retrospect, I still don’t know if it was a mistake to become emotionally involved. It was impossible not to see some element of my own life in each patient, and in each story. Indeed, I didn’t just see my mother embodied in the ICU patients, but other friends and family members. Was I treating these people differently, I wondered, spending a moment extra during pre-rounds or empathizing with their situation a little more, merely because they reminded me of someone? How could I play favorites with the critically ill? Would being detached instead allow me to deliver better care?

Once or twice I envisioned myself tied to the hospital bed, padded cotton straps tethering me to the side rails, preventing me from escaping or pulling out my breathing tube. (What if I wanted to self-extubate? Why had I lost that right?) How would my family react? Would they become an element in the room, an unstable piece of furniture to be treated with care until it could be fixed? Or would they avoid the hospital entirely, finding themselves a false freedom being out of the unit, but trapped by the knowledge of my illness?

As medical professionals, our dichotomous privilege and burden is knowing people in their most vulnerable moments. Though we’ve been entrusted with their intimate secrets, oftentimes we’re still just strangers, unable to say with certainty what the patients would want, or even what we think they should do. For that moment, it doesn’t matter how many other patients we’re juggling, we must temporarily become myopic and make them our priority. The egocentric view washes over us, too: we can’t help but fall back on what we would want for ourselves and our loved ones in that situation. After all, we work in a grey area, where nothing quite ends up like the textbook. Our boundaries are the law and our own morals, and, to be sure, Hippocrates’ call to “do no harm” can be subjective. How does doing what you think best fit in with legal and moral obligations, when in some situations the law seems to supersede personal beliefs, and in others, defaults to it? The most fair and responsible decision-making, I think, comes from recognizing and weighing personal preferences and interpretations in the context of the person we’re serving. They come to us asking for help, either explicitly, or by their inability to do so, and they’re the ones that have to live (or die) with our choice.