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A Doctor's Dilemma

Jessica Zitter

It was my first day at my new job, practicing a new specialty. Having spent fourteen years as an ICU physician--including a four-year pulmonary/critical-care fellowship in this very hospital--I had just completed a palliative-care fellowship. Now I was the hospital's palliative-care consult attending.

When I set eyes on the patient in room 1407, my first thought was: THIS LADY NEEDS TO BE INTUBATED--STAT!

The only trouble was that my job was to ease this patient's passing, not to prolong her life.

The team had told me that Mrs. Zelnick, an eighty-two-year-old widow, was dying from pneumonia and didn’t want to be put on life support.

What a breath of fresh air, I'd thought. Too often, as an ICU physician, I'd been tasked with keeping dying patients alive--here, I was being asked to honor an elderly woman's request to die in peace.

But it wasn’t going to be that simple.

Mrs. Zelnick, a beautiful woman who bore a striking resemblance to Anne Bancroft, somehow remained elegant even in her distress.

Her chart documented a surprisingly benign medical history: she'd suffered no real medical problems until a few days back, when she'd been brought to the emergency room for a bowel obstruction.

Over the next three days, while the obstruction was clearing up, a pneumonia had blossomed.

Now I noted Mrs. Zelnick's confusion, rattling breath and blue lips--clear signals of respiratory distress. This was not good.

A Filipino woman sat at the bedside, crying softly.

I introduced myself and asked, "How do you know Mrs. Zelnick?”

In faltering English, she explained that she had been Mrs. Zelnick’s housekeeper for the past eight years. When Mr. Zelnick had died, three years ago, she had moved into the home at Mrs. Zelnick’s request.

“She was all alone. Lonely. When he died, she had no children, no friends. She was always so sad and didn’t want to talk much. I tried to cheer her up, but...." She shrugged sadly, then lifted up Mrs. Zelnick’s forearm and pointed to a line of numbers tattooed on the inner side.

My heart dropped. This woman was a Holocaust survivor. She looked like my grandmother, the archtypal Jewish grandmother. Something inside me melted. I wanted to pick her up, to cradle her. I longed to shield her with my own body from all her suffering, past and present.

And I didn’t yet know the half of it.

Scanning Mrs. Zelnick's chart, I learned that she had been imprisoned at Auschwitz, where she had fallen victim to Dr. Mengele's insane "experiments." He had removed her uterus, leaving her with embarrassing abdominal disfigurement and intermittent small-bowel obstructions. Her twin sister had perished, along with her entire family. After the war, while in a displaced persons camp, she'd married another survivor, and they had eventually made it to safety in America. 

A firestorm was raging in my head. Pneumonia is treatable...if we put Mrs. Zelnick in the ICU and gave her respiratory support and antibiotics, she could be back to normal in a few days. 

But I felt confused and rudderless. What type of doctor was I supposed to be--one who would bring this patient comfort but perhaps miss a chance to save her life, or one who would, in trying to save her life, inflict painful and terrifying treatments upon her--treatments that she'd supposedly refused?

Palliative care is famous for providing less aggressive care without hastening patient mortality. Here and now, if things went badly, I might singlehandedly reverse that trend. Not a good move, your first day at a new job.

I called Mrs. Zelnick's primary medical team, and we huddled outside her room.

“She wasn’t improving,” the young attending explained. "I told her that she could either have a tube placed down her throat and go to the ICU, or go to the palliative-care suite and be comfortable. She wanted to be comfortable."

"But do you think she understood?” I asked, trying not to sound judgmental. “She has high C02 levels; she's confused. Also, she’s a Holocaust survivor. She’s probably terrified of anyone doing anything to her. Maybe we should just sedate the hell out of her and intubate.”

Clearly, the team found my words distressing. They too had struggled with this case--and they'd made a choice. The morphine they'd administered had eased Mrs. Zelnick's shortness of breath. She was quieter, more peaceful than before, and they were feeling relieved. They had called me in to support their decision and help ease the patient's passing. Instead, I was making it harder.

“I’m just not comfortable intubating her,” said the attending. “I feel like she was awake enough to understand me when she made her decision.”

There was some murmuring.

“I’m not sure she really got it,” the respiratory therapist piped up.

“Look,” said the attending. “I spent fifteen minutes with her, I did the best I could to persuade her, and she really didn’t want the tube. I would feel like I was going against her wishes if she got intubated.”

“Would you consider trying noninvasive ventilation overnight?” I asked desperately. Maybe a tightly fitted mask would be enough to turn her around.

But it turned out that we'd need an ICU bed to go that route, and the ICU attending refused, saying that the beds had to go to several ER patients who needed breathing machines and who had expressed a wish to be resuscitated if need be.

I was at a loss. Mrs. Zelnick was too sick to stay on this floor, but too close to death to go to the ICU.

At that moment, the respiratory therapist tapped me on the shoulder. "Let's at least try the mask. I’ll be on most of the night, and I'll keep an eye on her.” 

Later that evening, I slunk out of the hospital. Had I made everything worse? Mrs. Zelnick was still confused and uncomfortable. The team was upset with me. And I was doing something that I'd been trained never to do--use noninvasive ventilation on a patient who wasn’t fully alert.

The next morning, my worst fears were realized. Delirious and terrified, Mrs. Zelnick writhed in the bed, her mask off-center and totally ineffective.

"I tried all night to keep her mask on," the nurse said, "but she keeps pulling it off. She’s afraid that she'll suffocate."

I knew that I couldn’t save Mrs. Zelnick without full ICU care--and I didn’t know if she'd even want us to try. Was I projecting my own values onto someone who legitimately preferred to die in comfort?

I made a decision: I would be a palliative-care doctor. I would not increase Mrs. Zelnick's suffering again. I had the expertise to keep her comfortable, and now I would use it.

I called the palliative-care floor. “We have a patient coming up. Please prepare a morphine drip.”

Mrs. Zelnick died comfortably four hours later, as I held her hand.

I still wonder: What was the right approach? And I still don’t know the answer.

Although patient-centered care is everyone’s goal, many things can get in the way. The medical attending and I had disagreed on Mrs. Zelnick's treatment. He was earnest, young, and he wanted her suffering to stop, whereas my opinion was colored by my previous critical-care training and by my intense resonance with her history. She was part of my tribe.

I know that we all wanted the best for Mrs. Zelnick. I just wish I could be sure that we'd known what that was.


About the author:

Jessica Nutik Zitter is a physician practicing pulmonary/critical-care and palliative-care medicine. She works at Highland Hospital in Oakland and is an assistant clinical professor at University of California, San Francisco. Her work has been published in the New York Times, San Francisco Chronicle, JAMA and The Atlantic Monthly. Her website is jessicazitter.com.

Story editor:

Diane Guernsey 

Comments   

# Rob Burnside 2014-10-11 18:55
As a paramedic, I rarely knew what happened to critical patients who made it beyond the ED, which was a blessing to the extent that ignorance can truly be bliss. You didn't have the same luxury. And you didn't have the benefit of knowing the patient well enough to make a very difficult decision based on what she would most likely want if fully informed and rational. What else could you have done? Most would agree your choice was right, and most would salute you for the way you managed it--giving the alternative a chance. All should be grateful for your willingness to share the story, and for your ability to tell it so well. Thanks, and count me in.
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# Brian Kaye 2014-09-14 02:20
Thank you for sharing this gut wrenching story. I appreciate your honesty in a case with no easy answers. You tremendous humanity makes you a wonderful physician. We are fortunate to have you as a colleague.
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# Andrew Gallan 2014-09-13 21:48
Thanks for sharing. It made me feel, think, and consider one of your last lines: "Although patient-centere d care is everyone’s goal, many things can get in the way." Unbelievable.
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# Steven Weisman 2014-09-13 18:25
You did the right thing. May she rest in peace and her memory be a blessing for us all.
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# marianna crane 2014-09-13 12:12
Thank you for this touching story. We rarely hear about a doctor's dilemma in letting a patient die if that were her wishes in spite of the possibility she could be saved. This will continue to be problematic as more of our patients choose Palliative Care. You have opened the discussion among all the professionals who will provide comfort care over cure.
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# jegas 2014-09-13 08:28
Maybe you came into the picture a tad late. She could have been far gone for any good to occur. The confusion caused by CO2 retention added to the addition of morphine, a respiratory depressant, further aggravated the matter. All good intentions but a little too late. Shows timing is so crucial
in critical decision making.

,
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# John Connolly 2014-09-13 07:26
Jessica, an intense and touching story.it demonstrates that end-of-life care and decisions are not as simple as many people make them out to be--and the physician is in the middle. John
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# Pris Campbell 2014-09-13 05:27
Thank you for sharing this story about a difficult quandary. What a survivor this woman was, all of her life. In my opinion you made the right decision. That was her wish and you honored it. Sometimes we've simply reached the end of cur path, even if we could possibly be saved,.
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# John Messmer 2014-09-13 00:52
When you are trained to be aggressive and prolong life it can be very difficult to accept anyone's death. Even if she could have been treated and improved in her status, would that have been correct? She might not have fullly comprehended AT THAT TIME but she had been through enough to know that she was at life's end. She had been through so much in her life, clearly she knew what she wanted. Even if you had helped her recover from this event, then what? Just because we can reverse a process, does that justify doing it? Moving from critical care to palliative care is an interesting transition. Good luck.
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# David Power 2014-09-12 22:22
Thank you for the honesty with which you've shared your somewhat unique dual-training in both the ICU and hospice worlds! This was a nicely written piece. From what you write, it sounds like the ICU transfer would have been the wrong decision. It amazes me how often we as doctors seem to forget that everyone will die - we spend so much energy (and money) trying to prevent the inevitable. Thanks!
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# Lee Kagan 2014-09-12 21:42
Great piece, Jessica. Cleanly written, nicely paced.
As a physician and son of Holocaust survivors (father passed at 83 of ALS, mother still alive at 91 with moderate Alzheimers) I know well the conflicting feelings that arise when caring for "members of my tribe," particularly the tribe of survivors.
The loose piece in the clinical story you dealt with was whether or not the patient was competent to clearly understood the reversibility (of lack of reversibility) of her condition. You chose to spin it in favor of patient probably not competent and illness probably reversible. I applaud your insight into the feelings that pushed you that way. I've been there myself. Tough spot.
I've learned to err in favor of the patient's wishes. Maybe she was ready for the nightmares to end. Maybe she was ready to meet up with her lost family members again. Two things I know: Death didn't frighten her. And she was tougher than any of us.
Thanks for this.
Lee Kagan
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# maggie mahar 2014-09-12 21:57
Lee--
I found this post troubling, and appreciated your comment.

As a son of Holocaust survivors you are in a far better
position than I to know whether the physician was right to factor in her holocaust survivorship when deciding whether or not to consider what seemed to be her wishes--. . .

As you say "She was tougher than any of us." And, at her age, very likely she was ready to face death.

I appreciate the fact that you are not blaming the doctor.

But I do think that all of us (relatives, doctors and others) need to put our own feelings aside when considering a
patient's last wishes.

At a certain point many patients are ready to die. We should respect their
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