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."