“I’m not a doctor,” Ingrid Hansen said, sitting in an orange plastic chair next to her mother. “I’m still trying to wrap my brain around what happened.” I brought another chair into the room and took a seat. “She was fine a week ago.” Her green eyes darted back and forth as she stared at the floor; Ingrid wore knee-high leather boots and a nose ring and couldn’t have been a day over twenty-one. She took a sip from a large cup of coffee and reached for her scarf, which was resting on her purse. From the looks of things, she hadn’t slept in days.
I tried to calibrate how close it was appropriate to sit. What was the right way to do this? I slid my chair a few inches closer to Ingrid, and she looked on as I briefly scanned her mother’s ventilator settings. “Tell me what your understanding is thus far,” I said, parroting a phrase Don often used with families.
“I don’t know,” she said. “Someone found her. She had a heart attack, she had a stroke. She won’t wake up.”
As with so many of my patients and their families, I tried to imagine what their home life was like. Was she close with her mother? Did they talk on the phone? Did they fight? Did Ingrid truly understand what her mother would want in this nightmare scenario?
“She had a massive heart attack,” I said, measuring my words. “Blood wasn’t able to pump to her brain. We don’t know exactly how long she was down.” I fought the urge to look away when Ingrid’s lower lip began to tremble, and again I thought of my own mother. “She suffered profound brain damage,” I went on. “There is no brain activity.”
“Oh…God.”
I could feel a part of myself shutting down as Ingrid’s eyes welled with tears. It had become a slightly habitual reaction since Dre, when I was faced with such raw suffering, but now, with my health in the clear and my position at the hospital feeling more secure, I knew I needed to break myself of it. I took Ingrid’s soft hand in mine and searched for words as ventilator and blood pressure alarms blared in the background. My hand was cold, and I could tell it wasn’t providing comfort. She flinched when my palm touched hers and I thought she was going to pull away, but she didn’t. Her lower lip continued to tremble. When she closed her eyes, a tear dripped down her cheek. “We have the option to scale back.” I struggled to find the right balance between staying empathetic and not crying myself.
She took a deep breath and dabbed her cheeks with her scarf. “Is she suffering?”
“That is a concern, yes.”
“I don’t understand.”
We sat in silence as I considered my words. I wasn’t sure I was handling this conversation the right way, but it didn’t feel like the wrong way either. I felt my pager buzz and fought the urge to throw it against the wall. “Sometimes there’s no rhyme or reason,” I said softly.
“I just don’t…How can she be suffering if there’s no brain activity?”
I did not have an answer. And then, a moment of terror. What if this was the moment Baio had been talking about—a time when I was instructed to do something that I shouldn’t? Something that was wrong. “There are certain things we know,” I said. “We know that—”
As the words trickled out, I became less certain. During rounds, when the team had discussed Marlene Hansen, I had been called away to transport a patient to the MRI scanner. I hadn’t been there to hear just how dire her case was. It was clear from reading the notes of other physicians that a consensus had been reached that she no longer needed to be in an ICU, but I was technically relying on secondhand information. I was basing my conversation with Ingrid on the opinion of Don and experts whom I barely knew—medical consultants who had only met Marlene Hansen a day or two ago. What if they were wrong? What if I deferred this conversation until morning, when the rest of the team was available? What if that caused Benny to remain stuck in the emergency room because no ICU or CCU beds were available?
“I’ll do what you want,” Ingrid said softly, removing her hand from mine.
“You shouldn’t do what I want. And difficult as it may be, you shouldn’t do what you want. You should do what your mother would want. Have you ever discussed what she might want in this situation?”
“No.”
“But you are her healthcare proxy?”
She nodded. “She doesn’t have anyone else.”
“There is something called comfort measures only. We won’t draw blood, we won’t poke her with needles. We’ll make her comfortable.”
“I thought she couldn’t feel anything.”
“Right.”
“If she gets an infection, would you give her antibiotics?”
I wasn’t sure. I hadn’t even been present for the discussion on rounds about what was appropriate. Ingrid took her mother’s hand and kissed it. “I don’t want her to suffer,” she said. “I trust you. Just show me what I need to sign.”
I closed my eyes and bit my lip. I had been sent in to carry out a mission—to get Marlene Hansen out of the ICU—but it was clear that I didn’t have all of the necessary information. Maybe in a few hours I would, after I’d reviewed all of the notes from other doctors, but at that moment I wasn’t sure about very basic things like whether we’d provide antibiotics.
I mostly believed I was doing the right thing, but I wasn’t certain. It was impossible to know everything—I’d never know how to read an electroencephalogram, I’d never be the one to perform dialysis; those were jobs for experts in neurology and nephrology, and I had to trust them. If they felt Marlene Hansen had no hope of recovery, they were probably right. But what if I’d met Marlene instead of Benny? What if she was the patient trapped in the hospital—the one I visited day after day—the one I felt an emotional attachment to? Would this conversation have played out differently?
I wasn’t sure.
A moment later, I returned with the paperwork and handed Ingrid a pen. As she signed her name, I imagined myself taking the pen back, tearing up the papers, and telling Don that Ingrid wasn’t entirely sure what her mother would want. That was the truth of it. With space available, it seemed prudent to keep Marlene Hansen in the ICU until Ingrid figured it out. But what purpose would that serve? Was Ingrid going to suddenly recall some distant conversation with her mother about her end-of-life wishes? Was she going to remember that Mom actually wanted to be kept alive at all costs for as long as possible, even if she was brain-dead? The reality was that Don had a better grasp on how to keep the flow of traffic moving in the hospital; allowing emotions to get involved would introduce subjectivity. And subjectivity could screw things up for all of the other patients.
I kept my mouth shut and let her sign the papers.
“Nice work,” Don said as I leaned over a filing cabinet and placed the paperwork into Ms. Hansen’s chart. “We’ll send her out in a few hours.”
“Few?”
“They got a bed for Benny in the CCU.”
I jolted upright. “What? So Hansen can stay?” I felt like I had been punched in the gut. Don took a bite out of a tuna sandwich and patted me on the shoulder. “Hospital doesn’t function when we’re at capacity, Matt. Gotta have a bed available if there’s an arrest on the floor. Hansen needs to go. This is a no-brainer.”
“Gotcha,” I said softly.
He inhaled the remainder of his sandwich. “Get something to eat and then let’s do a vitals check on the unit. There’s more tuna in the lounge.” And with that he headed down the hall, looking like a man who knew much more than I did.