Perspective
The First and Last Days of Medicine
On a busy morning, a doctor stops to ask what a patient really wants—and finds out it isn’t more treatment.
By Maura Scanlon
Day 1 of Med 1 morning rounds. I tentatively follow a long train of white coats down the hallway toward Shirley E’s room. As our Firm D team approaches, her low-pitched moans and high-pitched wails forewarn us of the rollercoaster that lies ahead. We find Shirley, a robust woman, with her gowns and draping strewn about her bare yellow body, which is thrashing. Her 30-something daughters stand in the corner of her room, embarrassed and defeated by their mother’s illness.
Following Dr. M’s lead, we attempt to calm and redress her, and bandage her IJ port while asking about her favorite foods, her children, and other things. Although unable to identify time or place, Shirley’s encephalopathic mind quickly recognizes our poorly camouflaged attempts at distraction as an insult to her personhood.
She won’t have it.
I couldn’t believe this was my first patient on my medicine rotation, and I feared the next one. Shirley was nothing like the pediatric patients I had seen on my previous rotation or the painfully polite actors playing patients in our Physician and Patient class. That morning, we saw a fair number of patients with altered mental status. However, none were like Shirley. As the days and weeks passed, no other patient proved to be as informative, comical, emotional, and real.
I quickly realized that through Shirley, I was learning not only about the art of diuretic and lactulose titrations but also about how quickly hope blossoms with the subtlest signs of improvement and how quickly it can fade.
We were encouraged as Shirley progressed from knowing which country she was living in to knowing the name of the hospital she was in and on which side of the Mississippi River it was located. As her chronic liver failure was managed over the next two weeks, she seemed to improve and almost become well. We grew close as we celebrated her simple joys. Her daughters began to refer to Dr. M as “part of the family.” On the day of her discharge, I walked into her room to find her sitting upright in the chair beside her bed eating Cheerios. “Just a dabble of milk and sugar, just right,” she said with a yellow, toothy grin.
We thought she was a true success story, a patient who had recovered from a flare of nonalcoholic steatohepatitis (NASH), and who had several good years of life yet to live.
To our surprise, Shirley returned to us a few days later much altered—puffy and in distress. The CT scan of her psoas abscess upon discharge likely had induced contrast-nephropathy—acute renal failure, on top of her NASH. This time, it was not only her edematous and jaundiced body that ailed but also her spirits.
“Why did this happen?” she asked. Along with our new attending and the resident team, we tried to explain that this turn of events was just how her body was reacting. We tried to tell her that we were still hopeful for a liver transplant and gradual resolution of her newly developed acute tubular necrosis.
One morning Shirley told us about her nightly hallucinations—a white curtain floating, hanging over her bed, turning into a spooky black drape. Her dreams seemed strikingly symbolic of her disease and her mood, as one day she was improving and cheerful and the next she was on dialysis, feeling hopeless.
Over the course of three more weeks, Shirley’s determination and will to live slowly faded. Yet as her spirits sagged and her abdomen swelled, her witty mind stayed clear. One day, a resident made the mistake of entering her room with a Coke. She joked that since she was fluid-restricted, no one should be allowed to drink in her room. Every morning after that, as we circled her bed, her eyes would dart around the room to make sure no one had a beverage.
During morning rounds on the last day of my medicine rotation, Shirley asked me a startling question: Is it worth it?
She wondered how the dialysis port and peg tube that had been inserted were going to affect her life. I was initially taken aback. But as I thought about it, I had no doubt that every single one of the doctors, nurses, and others taking care of her had silently wondered this. Yet we had all assumed Shirley wanted this care, even though she never explicitly told us she did. As it turns out, at a care conference earlier in the week, Shirley’s family, not Shirley, had decided to move forward with the dialysis, peg tube, and transplant listing.
On the final day of my rotation, Dr. M, like an angel sent back to our service seemingly just for this patient, crouched next to Shirley at her bedside. With a soothing but strong voice, Dr. M explained at length that the decision whether to be treated was hers—not ours, not her family’s. He said we could continue to treat her, hoping that her kidneys would return to function and that a liver would become available. Or, we could simply stop it all, make her comfortable, and let her die in peace.
It then began to unfold. Shirley was tired and not interested in undergoing dialysis three times a week; she did not really want a new liver or a life on transplant medications. She was exhausted, but content. She was ready to meet her creator.
In the moment when Dr. M crouched beside her bed, I discovered how important it is to get down on the patient’s level and discuss the important issues that are all too often swept aside. Dr. M presented the arguments for continuing treatment and for palliative care. As it turned out, Shirley was at peace with the idea of dying.
On the last day of medicine, one of the most poignant lessons on patient care gently revealed itself in a quiet voice. I could have missed it. Although sad, it was a tender moment as Shirley’s voice was finally heard.
It was a bittersweet end to our morning rounds and my medicine rotation. While trailing behind white coats on morning rounds, in a busy hospital, on Firm D, we learned about confronting mortality at the bedside. MM
Maura Scanlon is a third-year medical student at the University of Minnesota.