Mr. Rogers

Today, I am leading the team this morning in the intensive care unit (ICU) when we walk into the room of Mr. Rogers. Mr. Rogers is a 64-year-old gentleman with a past medical history of sarcoidosis, a disease that damaged his lungs over the course of many years to the point where he can no longer walk more than a few steps before running out of breath. Mr. Rogers has been living in a nursing home for the past few years, tired and fatigued, stuck in bed all day, with trips in and out of the hospital becoming more frequent every time his breathing worsens. In fact, he has been to the ICU several times over the past three months, and it has always been the same routine: Mr. Rogers has trouble breathing, is taken to the hospital where he needs to be sedated to have a breathing tube placed down his throat, is connected to a ventilator for the machine to breathe into his lungs, and then feels better after a few days. At this point we wake him up and take out the tube so he can breathe again without the machine … until the next time he runs out of breath.

But this time it is different. Mr. Rogers has already been on the ventilator for more than a week and his breathing is not getting any better. His body is fatigued, and his lungs are so stiff that he is simply unable to take a breath on his own. We have stopped the sedatives and have woken him up, and we are testing his strength by pausing the machine for a few seconds, but Mr. Rogers is not taking any breaths on his own. He is alert, awake, with the tube in his throat, the machine pushing air into his lungs, and too fatigued to simply take a breath.

Mr. Rogers can communicate by nodding his head or moving his hands, and his misery is apparent from his facial expressions. The next step in his care would be to perform a surgical tracheostomy, cutting a hole into his neck so that a breathing tube can go directly into the lungs, but Mr. Rogers makes it very clear that he does not want the surgery. Having been stuck in bed for the past few months, he does not want to be kept alive by a breathing machine.

This morning Mr. Rogers’s family gathered around his bed. The priest administered last rites, and his daughter held his hand as I motioned for the respiratory therapist to follow the wishes of Mr. Rogers and his family to pull out the breathing tube from his mouth. Together we stand there as the machine gives Mr. Rogers one last breath before the tube is pulled out. Mr. Rogers does not have the strength to take any breaths on his own. I ask the nurse to increase the dose of his intravenous pain medications so he does not suffer any discomfort gasping for air, and 10 minutes later I pronounce Mr. Rogers dead.

You see, this is the United States, where patients have rights and physicians are obligated to follow the goals of care outlined by their patients. Mr. Rogers’s mental status was sharp. He had good insight into his condition and his poor prognosis. He had the capacity to make medical decisions, and he very specifically requested to be liberated from this misery rather than staying alive, dependent on machines.

Mrs. Rosenberg

Moving onto the next room is our patient Mrs. Rosenberg. Mrs. Rosenberg is a 93-year-old great-grandmother who suffered a massive stroke that paralyzed her whole body and took away her consciousness, so she is being kept alive by a ventilator. Mrs. Rosenberg’s family is Orthodox Jewish, and their Rabbi advised them that every moment lived on this earth is a precious gift from God and all human life is equally sacred regardless of the quality of life experienced by the individual. Mrs. Rosenberg’s children would like for their mother to have a surgical tracheostomy for a tube placed in her neck so that she can stay alive on the breathing machine for as long as possible.

Unfortunately, Mrs. Rosenberg has an unusually short neck, and the surgeon at our hospital is uncomfortable performing the procedure because the anatomy of her neck will require the tracheostomy to be placed almost into her chest. She will need to be transferred to a larger tertiary-care center, where a thoracic surgeon can cut down a part of her breastbone to make room for the permanent breathing tube. After that, Mrs. Rosenberg will be transferred to a long-term-care facility, where she will be in bed on a breathing machine for the rest of her life, unable to move any part of her body, unresponsive.

You see, this is the United States, where patients have rights and physicians are obligated to follow the goals of care outlined by the family of their patient who is unable to make decisions on their own. Mrs. Rosenberg is in a coma, unable to speak for herself, and her family members at the bedside all unanimously agree that she should undergo any procedure available to prolong her life.

Mrs. Jones

Continuing our rounds, we move down the hallway and enter the room of Mrs. Jones. Mrs. Jones is only 29 years old, mother of two little children and wife to a dedicated husband. She is here in the ICU for internal bleeding. We finally stopped the bleeding this morning, but Mrs. Jones lost a lot of blood. Her blood levels remain critically low, and we are unable to replace it with a blood transfusion. Mrs. Jones is a Jehovah’s Witness, and her religion teaches that blood is a gift of life from God that cannot be accepted from another human being. Mrs. Jones will not sacrifice her religious beliefs, and her blood levels have dropped too low for any treatments other than a transfusion to be effective.

You see, this is the United States, where patients have rights and physicians are obligated to follow the goals of care outlined by their patients. Mrs. Jones has good insight into her condition and understands her poor prognosis. She has the capacity to make medical decisions, and she is requesting to exercise her right to religious freedom. Friends and family are at the bedside holding her hand while Mrs. Jones takes her last breath before we put her on a breathing machine. Later that afternoon, we watch as her young children become orphans because there is no longer anything else we can do to save her life without giving her blood.

Mr. Scott

Finally, we enter the room of Mr. Scott. Mr. Scott is a 53-year-old who is here in the ICU after shooting himself in the face. Mr. Scott has been struggling with depression exacerbated by other mental illnesses. He spent many of his teenage years in juvenile detention and most of his adult life going in and out of prison for a variety of petty crimes. He has no family to support him. He spends most of his time alone in an abandoned apartment. After two unsuccessful attempts at suicide by overdosing on his medications, he shot himself instead. The bullet took a wrong turn and destroyed his face, while his brain remained intact. A neighbor called the police after hearing the gunshot, and Mr. Scott now is kept alive on a breathing machine through a tube in his neck. He still has some remnants of what used to be a nose and cheeks, and the surgeon expects six to eight surgeries over the next few months to restore what will again resemble a face.

Mr. Scott is awake. He has good insight into his condition and understands his prognosis. He is expected to make a good recovery after all the surgeries, although with a distorted face, a hole in his neck for breathing, and a hole over his stomach for feeding. He is begging us to remove the breathing machine now, while his body still depends on it, so that he can pass away in peace, but we are keeping him alive because he does not have the capacity to make medical decisions.

You see, this is the United States, where patients have a right to live and physicians are obligated to preserve life for patients who do not have the capacity to make their own decisions. Mr. Scott’s suicidal thoughts indicate by definition that his mind is not functioning properly, and he therefore does not have the capacity to make medical decisions. We are keeping Mr. Scott alive until he recovers and can be removed safely from the machines to experience the precious gift of life. Or would it be more humane to follow his wish and remove him from the ventilator now?

Difficult Decisions

My moral compass’s needle can’t find true North in these cases. My training taught me that there is a correct solution to every question, even the hardest ones. But sometimes, in the United States, we physicians must aid patients and their families in carrying out solutions that we would never choose for ourselves.

Dr. Taub is an emergency physician at Ezras Choilim Health Center.