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Mr. Khatami* was a 70-year-old Indian man with decreased mental
status secondary to a large, left-sided stroke. The patient, a
veteran, was homeless and using cocaine at the time of his stroke.
He had been nonresponsive for the last 6 weeks, only able to
occasionally glance around the room, and given a poor prognosis for
any recovery of his mental status by the neurology service. The
patient had a nasogastric tube and was recently extubated. He had
active tuberculosis and was breathing with supplemental oxygen; he
seemed uncomfortable. He had bed sores in addition to sores above
his ears where oxygen tubing had been for the last month and a
half. He wore a diaper and had a urinary catheter in place.
I'd never felt conflict on so many intellectual levels before. I
didn't want my patient to die, or suffer. I didn't want the
minutiae of the law to keep me from doing what was right or to let
me do something I felt was wrong. I didn't want to burden our
health care system with futile procedures, and I didn't want to
lose my heart. The way I was thinking finally hit me—I was focused
too much on what I didn't want because I was afraid of the
consequences. I needed to figure out what I did want.
This experience created a sense of fear that I had never
known-and I was enjoying the challenge. I wasn't afraid of making a
mistake, getting sued, or receiving a bad grade. I was afraid of
how easy it was not to think about the choice in front of me. I had
just stepped into a gray area of medicine where being a passive
provider was still somewhat passable. I could easily still get an
MD after my name by letting social work handle this issue while I
studied diabetes medications instead. I was never going to be a
physician, however, unless I struggled through this.
Should my patient be kept alive or be allowed to die? He was no
longer able to guide us and was estranged from his family (save for
one son who hadn't seen or spoken to him in 15 years). Having just
seen my grandmother be painfully kept alive with no advanced
directive, I knew I wouldn't want to go on like this. The hardest
part, though, was to decide what Mr. Khatami would have wanted. He
was clearly in pain at the moment, but pain passes. The guiding
principles of beneficence and nonmaleficence became decidedly
blurred. One could make an argument that removing his NG tube was
maleficent, just as keeping this patient in pain with no recovery
was harmful. Normally, a patient's wishes would provide clarity;
beneficence with end-of-life care remains in the eye of the
recipient. Would Mr. Khatami want to go on living like that?
It's astounding how much further technology has come than
ethical comprehension. Incredibly complex brain surgery was done
while the Tuskegee syphilis experiment was conducted. In many ways,
we are like kids who can memorize and recite the entire
constitution without understanding its true implications. My
favorite move in academic medicine thus far has been an attempt to
cut down on excessive testing (that is, ordering a D-dimer test
less frequently). Still here, ethics has continued to lag behind.
In our "what if" ethics of medicine, many people try to control
every obscure scenario imaginable, even if it ends up deleterious
towards the care a patient would most likely have wanted.
The true dichotomy was that this patient could either live in
suffering, or be let to die in relative peace; he could not do
both. I liken this challenge to a differential diagnosis. In
medicine, a diagnosis becomes the most likely explanation, given a
physician's knowledge, experience, and personal perspective. I had
always thought that ethics would be like they were when I was
growing up, with a right and a wrong answer and a clear choice to
make. Unfortunately, there were no villains dressed in black on the
floors that day. We were going with our "best guess". Like any
diagnostic test, we were going to be wrong a small percent of the
For me, advocating for my patient meant pushing to forgo
life-prolonging procedures that would cause him undue discomfort at
no real added benefit. It meant fighting for decisions that were
going to shorten his life, something I'd come to grips with
intellectually but never thought I'd have to do, especially not my
second day on the job. Not surprisingly, even within our team there
were disagreements, as everyone had different perspectives and
experiences. In the end, the decision was made to bypass painful
testing to work-up the patient's stroke and move toward giving him
morphine to improve his quality of life. Not just a team of
providers but people hoping for the same depth of concern if the
situation were reversed, we agreed that this choice was best.
I spoke to Mr. Khatami on the last day that I saw him, as I did
every morning. Though I'd never gotten a response, I did feel very
close to him. When I was ready to leave the room, I held Mr.
Khatami's arm and looked at the man who had helped us all grow so
much one more time. My only feeling was hope, that we had done the
right thing. The feeling faded and was replaced with anxious
excitement at the prospect of our next diagnosis as I stepped into
the next patient's room.
Mr. Khatami died 10 days later.
NYU School of Medicine, Class of 2013
*Name and identifying references have been changed to
protect patient privacy.
April 2012 Issue of IMpact
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