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Daniel Lee

Primum non nocere. First, do no harm.

I learned that in the first year of medical school. "Nonmaleficence" is the fancy name given to this sentiment, and it's one of the four pillars of modern bioethics. In real life, it's an impossible standard: We harm patients all the time. But the spirit behind the principle is what matters. Do the least possible harm to patients as they go through the medical system. Do only what is necessary. Act only when the benefits clearly outweigh the costs.

As a third-year medical student on rotation in the intensive-care unit (ICU), I admitted David, an elderly man transferred from another hospital because a severe lung infection was making it hard for him to breathe.

When he got to us, he already had a breathing tube down his throat and was sedated for comfort, but his agonized expression transfixed me.

"Are you in pain?" I asked. He shook his head slightly.

Shortly after that, his family arrived--his wife and four daughters. Watching the way they encircled him, held his hands and whispered to one another, I could tell that this was a close family--a rarity among those I'd seen in the ICU. Often, families reveal their fault lines and fractures as they wrestle with who doesn't get along with whom, who will visit and when, and who will be the primary contact person. In David's family, these tensions were noticeably absent.

From David's wife, Susan, we learned that he didn't want the tube--he hated it, in fact--but that he'd agreed to try it for a short while to see if modern medicine could cure his infection.

"I asked him to do it for me," Susan told me quietly, a guilty look on her face. "He would do anything for me."

We turned the ICU medical machine loose on David. Stuck a camera in his lungs and cleansed them with saline. Put him on our most powerful antibiotic and antiviral weapons, their menacing names full of strangely juxtaposed syllables--voriconazole, vancomycin, linezolid, azithromycin. Because David's heart was weak, his body was full of fluid, so we tried to get him to pee it out. It might help his breathing, we thought. It didn't; in fact, he stopped peeing altogether. His blood pressure dropped, so we put him on strong pressors to keep his brain oxygenated.

Over the next forty-eight hours, I presented David during morning rounds, while the team tweaked his treatment plan here and there. The whole time, Susan never left the hospital; she stood in the back during rounds, silently taking in the words and numbers that must have made little sense to her.

As the team moved on to the next patient, I would stay behind with her and try to summarize our medical decisions.

"Basically, we're going to try switching out one antibiotic and increasing his diuretic dose to help get rid of some extra fluid," I told her on the second morning.

She looked torn. "Do you have any idea of his chances? I don't want to continue these treatments if he has no chance of making it. I promised him that."

I could only repeat the attending physician's words: "We'll know his prognosis better in one or two more days. Right now, it's too early to tell."

The test results started rolling in--and they weren't good. David's body was overrun by an assortment of viral, bacterial and fungal infections. That's a lot, even in the ICU. His blood pressure kept dropping, his kidneys kept deteriorating, and his face never lost that agonized look.

I couldn't help voicing my thoughts to the attending. "I think it's time to tell his family that he's past the stage where we can reasonably give him a fighting chance. He could be switched to comfort care and spend what little time he has left with his family."

The attending's reply was curt and final: "No, we'll give him a couple more days."

That evening, the nurse alerted us that David's blood pressure was plunging. I went to examine him.

His face was blue, his arms and legs were swollen and cold, fluid was leaking from small sores on his arms, and his face looked even more agonized. As always, his family was there.

I looked across at his oldest daughter, who had been cautiously optimistic until now. She looked back at me, tears welling up in her eyes.

"Dan, please, we need an answer. We can't continue to see him this way. He looks like he's in so much pain."

I groped for an answer. "I'm sorry, it must be very hard not to know," I said finally. "I'd be frustrated, too. I'll go ask for an update."

In the face of their distress, I felt so powerless. To me it seemed long past the time when we should have stopped aggressive therapy, but to say this to the family would, I felt, undermine the attending. Inwardly, I chafed at his handling of the situation: It seemed that he wasn't giving David's prognosis careful consideration. He'd been brushing off David and his family and ignoring their agony.

Later that night one of David's lungs collapsed. His blood pressure plummeted. We ushered his family out into the hallway, Susan distraught and crying.

David was sedated, a hole was cut in his chest, and a tube was inserted to reinflate his lung. He revived--barely. The whole thing took only ten minutes, but seemed much longer. The family was told that David experienced no pain, but I wasn't so sure: I'd seen him grimace when they cut into him.

Afterwards, I saw Susan walking the halls aimlessly, like a ghost.

Later that night, when the attending arrived, David's family asked that we stop all therapies.

The attending's response was brisk: "Okay, that's fine. We'll stop."

The next morning, we took the tube out of David's throat, and he passed away within minutes. I couldn't bring myself to witness his death--I had to leave the room. Feeling so emotionally attached to him and his family, I didn't trust myself not to break down.

I felt sad that David didn't get to pass away at home, in peace--and that his family had to see him die in agony. I'd felt so helpless to prevent their suffering: All of our accumulated medical knowledge had done nothing to ease David's suffering, or his family's. If anything, I felt guilty of being a cog in the machine that had inflicted even more pain on them. I resolved to do everything I could to keep this from happening again.

Did we do right by him? Did we do right by his family?

I don't know.

But actually, I think that I do know.

Since that experience, whenever I care for a critically ill patient, my memories of David return--and that phrase keeps running through my mind: Primum non nocere.


About the author:

Daniel Lee is a fourth-year medical student at the University of Minnesota, planning to go into emergency medicine. "Writing has always been a way to process my thoughts--a practice I've found crucial in understanding the complex, often messy situations that arise in medicine. Caring for David was one of my most gripping medical-school experiences. In many ways, it characterizes modern American medicine. I felt compelled to write about it to enable others to know and empathize with David's suffering, and to help the medical community move towards better care."

Story editor:

Diane Guernsey

Comments   

# Rita, RSW 2016-09-21 13:47
Thank you for writing this. It is a compelling story.
I couldn't help wondering if there was a palliative care team (or physician) at the hospital. I once worked in a hospital who had an oncologist who continued treatment regardless of prognosis, I would tell families about the "palliative care team" and suggest they ask for a consult from them. I knew they would tell the patient and family the truth about the situation so that they could make a reasonable decision.
Thanks again for a wonderful story.
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# Paula Mahon MD 2016-09-20 11:36
This is a great story, and one many med students can tell (I had one of my own-- very similar). I love the line about how ICU families show their fault lines and fractures -- fabulous writing. This story displays some of the difficulty with being a patient in a tertiary hospital-- you as a patient are going to be the lesson others will learn from--be it the insertion of a chest tube, the manipulation of vent settings, how far you can push a diuretic before renal failure ensues, etc. Because you have learned the lessons well I have faith you won't repeat them, but I SO WISH you were going on to do primary care. You'd be fabulous in that setting.
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# Margaret Fleming 2016-09-18 11:38
This really scared me. The patient, and even the "attending" can't really know how much time we have or if we will recover. In this instance, the patient and the writer, and the family seem to know, and probably feel that they know..
I'm not sure if a final plan I would write can be the solution.
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# Thomas Boniface 2016-09-17 20:38
Daniel - Thank you for your reflections. According to Edmund Pellegrino if you translate Hippocrates' Greek writings directly to contemporary English - skip the Latin - what he said was more like "do what is in the interest of the patient." There is a duality there, referring to both what is best for the patient and not what is best for the physician. Our fears and biases can and do impact our perceptions and recommendations . Keep those eyes and ears open, you will be great.
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# Ron Banner MD 2016-09-17 16:23
Dear Daniel,

A sad and painful story, beautifully told.

Clearly you have learned the lesson of Do No Harm, and your future patients will be blessed to have you as an attending.

However, the attending that David had did not know that lesson and probably never will.

Yet, there were seasoned nurses involved with David's care, and in an ICU, nurses are more than mere robots carrying out orders. What mechanisms does that hospital have to stop merciless care? Can the nurses call a Medical Ethics consult? Can the director of the ICU or the Chief of Medicine or the Director of Nursing be involved?
This is not the 19th century where whatever the physician says goes.

This is an important subject, not just for David's attending and hospital but for every patient, every healthcare professional, and every hospital.
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# L Haller 2016-09-17 13:08
As a family member who has lived through a similar scenario, I can unequivocally state that it is always best to keep the patient and the family informed of the patient's medical status even if the situation is dire. Personally, I think aggressive treatment against the patient's wishes should be avoided. In order to do that a conversation with the patient and family about the patient's prognosis has to occur. The quality time we could have spent with our loved one has been forever lost, and it is a wound that we will carry to the end of our days. Your commitment to do what is best for patients and their families gives me hope for other families in the future. I know you'll make a terrific Doctor. Best wishes for your continued success.
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# Pris Campbell 2016-09-17 05:52
Thanks for sharing this. I only wish the attending physician could have seen past 'try everything at thr expense of the patient's best interest'
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# Young 2016-09-17 02:17
Very sad story and we all worried about what if one of my family or myself is in that ICU situation.
Hope to trust the Doctor will have the" Primum none noncere" mind
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# Robert 2016-09-16 22:24
Wonderful description of a common scenario. I this case less would have been much more for the family.
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# Teresa Bacon 2016-09-16 22:13
This happens so frequently in ICU: Being Mortal should be required reading. This story is so well written and addresses a huge problem in critical care.
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# Margaret Peterson 2016-09-16 19:59
Yes, you do know. But it's not just your fault, or even just the attending's fault (although he certainly comes in for his share of responsibility) . The challenge is how to educate and support families not to hospitalize people in David's condition--i.e. , to recognize that out-of-hospital care is better for their loved one than is a hospitalization .
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# Janice Mancuso 2016-09-17 17:44
“Think higher and feel deeper.” ~ Elie Wiesel
*************************************
Daniel, with all due respect to Margaret, I do not think you bear "fault." Your questions are valid, but they’re not about assigning blame. (At least, that’s not how I read them.) "Did we do right by [David]? Did we do right by his family?" Indeed, you were part of the medical team, but you were not "the" (or even "a") decision-maker. It sounds like you did and said all you could as a 3rd year medical student.

As far as you doing right by David and his family... The fact that they—and this experience—left such a lasting impression on you (as a person, writer, and future physician) honors his memory and their love.

PS Maybe someday you'll write them a note to acknowledge the experience and express gratitude for the lasting lesson you carry with you. I guarantee they’ll treasure knowing how David mattered—and still matters—to you…and, as a result, to your future patients.
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# Janet 2016-09-16 19:30
You'll be a fine physician. Godspeed.
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