Original subtitles

(chattering)

- Good afternoon, Beth Israel Patient Information.

May I help you? - Room 616.

He's in room 588, take the blue elevators there

to the fifth floor, when you get off, take a left.

(relaxed flute music)

(relaxed guitar music)

- [Nurse] Kim to the cardiac room.

Kim to the cardiac room.

- Maybe just to adjust to get his respiratory

settings changed in such a way that he

doesn't look like he's breathing so hard.

I think it's a little bit disconcerting for

the family to come in here and see him struggling like that.

So that's just an idea, just a passing idea.

- What we should try is if we think

he stands any chance of being estivated,

I'm gonna call his family and tell him that

this is a situation, I'm spoken to 'em before.

They know the situation.

Tell them that it seems as though he's breathing on

his own and we should make an attempt, take out the tube,

leave it in God's hands, see what happens.

- Okay.

I don't know where you're at with that.

He has a heart rate of 140, he's got dependent crackles,

diffused wheezing, he may not fly.

So make sure that you and the family are quite clear

about whether this is sort of a we're gonna stop

ventilating him once and for all or we're gonna

try it and just see but make sure you've

decided before exactly what you're dealing with.

- I want you to understand the situation

and sort of where we stand.

I think what seems to make the most sense

to me at this point is that since his brain,

since he's never gonna wake up,

that it wouldn't make sense to continue on in this state.

Now we could try stopping the ventilator and if he breathes,

then he breathes and if he doesn't,

then it's in God's hands now.

Now I know,

but not knowing really how you felt on this,

I wanted to call and find out and we

hadn't actually spoken in awhile, so.

He is, so he may breathe on his own

and that's certainly a possibility but

it's hard for us to actually know that for sure

and I'm saying if we take it out, we may find out

that he doesn't, in which case he would,

if it were somebody who were alive and well,

we would put the tube back in but I think

given all the situation which you seem to understand,

it wouldn't make much sense to put

the tube back in because his brain is gone.

I know this is a very difficult topic.

- You know what the date is?

What month is it?

Is it winter time?

- [Nurse] I'm gonna just slide you over.

- Ready, one, two, three.

- How you feeling this morning?

What's that?

Can you look over here, look at my fingers?

Can you follow my fingers?

- We'll let you do your work too.

I'm gonna get you weighed Mr. Toomey on a special scale.

Just lifting you up in the air.

- [Nurse] 86.2.

- A special gift for ya.

(chattering)

- [Man] Yeah, I mean whatever.

- I think it's important that everybody

feel comfortable with what we're doing.

I personally think that his antibiotics are,

you know it's like

a pea shooter against an atomic bomb.

I mean the guy is not, if you look at

the natural history of what's happened here

and what his prognosis is and what we know about

the terminal lung cancer, there's not anything

any of us is gonna be able to do and whether

you give him the antibiotics or not I think is

sort of more how you feel personally about it.

I guess the issue that's gonna become

a major issue is that everybody feel

comfortable with sort of withdrawing his care.

I certainly do, I mean I think that on Friday night,

I've never thought that when the guy arrived here

that he had a chance of pulling through but

I do think it's very important for the family

to give them the feeling that we're doing

everything that we can 'til the point that they

come to the realization that, I mean there

are a lot of unresolved issues here.

Never dealt with his feelings with his younger daughter.

A lot of anger on both of their parts evidently

and both, you know he's been married for 34 years.

A lot of other, and I think they all,

they didn't have a chance to say goodbye to him

and that was the thing that was really irking them.

I think they sorta knew intellectually that

he wasn't gonna make it but emotionally on Friday,

they were just not prepared to accept that

and I think now that they've really evolved

to a different stage in their own feelings,

I think that we've gotta sorta take that into account but

always in a situation like this there

are four or five different groups of people here.

The nurses know, knew from the moment he

walked in the door that he wasn't gonna make it

and I think that the family was a bit angry that

they were getting that message from the nurses.

I sorta knew that too but I didn't give 'em the same

message, I sorta said yes, we're gonna do all this stuff.

But everybody's gotta feel comfortable that we're,

before we sort of embark on a course of

action here that we're doing the right thing.

I mean nobody likes to lose.

But this is not something that

we have a lot of control over.

But I think if people feel different about it,

now's the time to say so because I think that we're gonna,

I'm gonna have to talk to the family

sometime today about withdrawing support

and my own personal feeling is that

I don't think that we have, it's just a question

of he's dying today or dying three days from now.

- I mean the acute deterioration on Saturday

is really what turned the family around

and since then they've really, it sounds

like they've just really evolved in

their feelings and in their wishes.

- [Scott] But I was really

asking the question for everybody here.

- Well it was my feeling before he had

this deterioration on Saturday that if he

were to stop bleeding long enough, presumably

he could eventually mobilize that blood,

re-expand and potential come off the vent.

In which case he'd be at XRT and if he

didn't re-bleed, he could have a couple of months.

But now he's showing that he's just

bleeding again back to where he was before.

He's not gonna stand a chance of ever getting off the vents.

- Yeah, as somebody who treats a lot of lung cancer,

I don't think there's anything in the medical

literature that would justify the optimism of the radiation

therapists in terms of what they said even on Friday.

- But the oncologist too.

We've got the oncologist down there.

I mean Annette said "Well, he could've gotten

"three days of XRT by now but now it's too late."

And I said that wouldn't have made any difference.

He bled Saturday morning.

- [Scott] Okay.

Mr. Gavin, he did not report any chest pain yesterday.

His CPK from the previous day is ruled out.

His VEA was at baseline yesterday.

Over the course of the day, he remained on

the drips he was on yesterday, ranged with

dopamine, pyrrobutamine and his nitroprusside

had increased over the course of the day

and tolerated a blood pressure of about 80.

Keep doing that and one dose of diuretics in the morning.

- Hang on.

All right, it's charged.

- [Nurse] Unplug her from the EKG.

Turn it on. - I got it, I got it.

- [Doctor] All right, let's shock, check her blood--

- [Nurse] Wait a second.

Clear.

- There's no pulse.

- [Doctor] Continue with CPR.

- Towel.

- Wait, I need this.

- [Nurse] Is there something disconnected?

- Yes.

- Full CPR for just a second.

All right, that's it.

- Unless anybody has anymore ideas.

- But he has told us that he

does not want to live on the tube.

- Right. - Okay.

That he's made clear to me, he's made clear to you.

That's been his major concern all along.

So that if at some point you're saying

we can't wean him, then I think that

per se is,

to me at least that per se in an indication to stop,

to DC the tube.

What he is saying, what he has indeed said is

"I do not want to live on the tube,

"I don't want the tube if I can't get off the tube."

- Right.

- So if you hit that point, then yes, you DC him.

- They got in touch with her son

who insisted that everything be done.

So they looked for everything but,

I mean everything, a septus and a ruptured viscous

to explain her acidosis, hypotension and decreasing crit

and it became clear as she became

recurrently hypotensive with this distending

abdomen that this was a ruptured aneurism.

The surgeons--

- As far as I know, that's not a medical disease.

- The surgeons evaluated her

and Mark Lanser's note said

a short, you know,

HNP impression, ruptured aneurism.

Operation is futile, 100% mortality.

I have spoken with the son

in charge and explained the situation

and he suggested comfort measures.

- His son? - No.

Mark Lanser, the surgical attending.

Comfort measures and no resuscitative efforts.

The son insisted that everything be done

and the son I think is now flying here

from, I don't know where he lives

but he's apparently in a plane.

I think that there are two more, I think there

are two daughters but they haven't been contacted and so

the EW nurses felt too uncomfortable having her downstairs.

She's in the midst of becoming hypotensive and

distending abdomen, she got intubated

which is why she has to be here and she was put on

lots of depressors, now is on Livo and Neo.

- [Scott] Sounds like we're doing everything we can do.

- So I said why does she even have to come to,

but we won't even get into that.

- That's not worth-- - No, it isn't.

- That's fine, I think it's, because

one of the reasons we're having her here

is that we deal with this better than anybody else.

- See the big issue was because the nurses felt that

when she dies, she has to be coded

because the son insisted everything be done

and so they were preparing to do a code on this poor woman.

- I guess the question is

there are lots of definitions of everything.

- She's also gotten four units of blood

and I assume by carb and stuff because

it looks like her gases got a little better.

Crit seemed to stabilize.

- She hasn't had a gas intrusion today.

- She had one a little bit later.

But I mean the bicarbs on her SMA segment,

there are some bicarbs that's getting better.

I guess I don't see the point in doing

any of that because I agree, this is a surgical

disease and if they're not gonna do surgery,

I don't see the point of prolonging it.

- [Doctor] We'll talk to the son.

- Yeah, I mean again I think that

you know, go ahead and take a quick look at her and

I don't,

I don't know.

What's happened with these, the DNR rules and everything

over the last five years really makes, puts you in

a difficult situation, I think that I would

feel very comfortable in terms of everything,

being everything that we've done already.

- Is she awake now?

- [Doctor] She's awake a little bit now more,

she has a baseline dementia so I don't know what her

understanding is but she is a little bit awake right now.

- What's the son's understanding?

- [Doctor] He understands that

basically it's a surgical problem and they

cannot treat it surgically and medically

there's no further thing we can do and

that you know like I said,

"Please understand that she already died."

- Does he want to make plans to come here at all?

- [Doctor] He's coming here.

He's gonna arrive here around 12:30 in the hospital.

He's planning on coming from Chicago at 11:30.

- Do you think she'll survive 'til then?

- [Doctor] I don't think so and he knows that.

- He does? - Yeah.

But I think it might make him

feel better if I had talked with you.

- I'll put a note in there. - Okay, thank you.

- Okay fine.

Mrs. Winter, this is Rabbi Baird, can you hear me?

Just blink your eyes if you can hear me, okay?

Blink your eyes, this is Rabbi Baird.

Can you hear me at all?

I've come by to say hello.

We understand that your son

is going to be coming from Chicago.

Hopefully he'll be here this morning,

later this morning, okay?

And I wanted you to know that I'm here as well

and we're going to be here with you.

We won't leave you alone, okay?

- [Nurse] Thank you.

- [Nurse Operator] Amy, line four.

- She can't hear anything.

Let's take her off this for a second.

(electronic beeping)

- Okay, she's dead.

10:53.

- She's gonna be here for awhile.

- Basically it's not just his middle lobe that's down.

His lower lobe is completely down and his middle lobe.

My general approach in terms of dealing with

the family about something like this is just that

even if they can't hear it, I think it's important

to tell them exactly what is going on

and if they don't, if they don't get it the first time,

it's not so bad.

If it's so frightening to them that they can't hear it,

then that's okay, I don't think you're gonna do 'em

any harm but I think that it's important to be honest

with them and tell them exactly what's going on because

eventually they will start to hear I think what's going on.

I think probably what I'll say is

similar to what I said this morning.

- It's an interesting challenge because while

you've been talking to the mother saying this,

the daughter will be in the background going

like this, it's a very bizarre situation.

I just went on despite what the daughter was signaling.

I just kept saying it but it's unusual.

- Well again I think that

as we said this morning on rounds,

it's a very difficult situation.

The mother says she doesn't want to hear anything

but these daughters that are all fighting for

control but I don't think that reasonably

you can exclude her from the decision-making process.

- In the scope of one to 10 of your lungs,

10 being good and one being bad, you're on a one.

You have really poor, poor breathing.

- That's the condition I'm in. - Yeah.

- How is it, I could breath yesterday,

the day before yesterday.

- Falling, yeah. - Falling.

- And I went home, no care or nothing.

I went home, they took me home.

- Yeah. - All alone.

- Yeah.

But then it's what happened yesterday

that's made you feel bad.

Why did you go to Dr. Axelrod's office?

- My sons took me there. - Yeah.

Yeah, was that because you

were having a hard time breathing?

- No.

- No?

It turns out you were.

- He's my official doctor. - Right.

I understand that, what I'm asking you is what,

did your sons come over and see that

you were a little bit worse and they said--

- They dropped me off. - Okay.

- My sons dropped me off.

- Did they bring you to Dr. Axelrod's because--

- I told them to. - You told 'em to

because you were feeling bad?

- No, he's my doctor.

- I know, I know.

Was it a regular appointment or were you feeling, oh.

- It was to be this week. - Oh, I see.

- But I got hurt last week, so he says "Bring him up."

Then from there he brought me over here.

- So it wasn't like a new thing that

you were feeling all of a sudden bad and you went

and called him and said "I need an appointment."

It was already scheduled.

Oh, I didn't know that.

- I went to see him. - Yeah.

- I lost my wife here. - I know you did.

- And I was here in '83. - Yeah.

- Myself.

- Do you understand what intubation means?

- Yeah. - Do you understand?

- Raise you up.

- No.

No, that's not what it means.

Intubation means, it's an act of putting a tube

in your mouth and into your lungs

and we attach it to a machine through tubes

and we help you breathe

and we wait for your lungs to get better

and then we take you off the machine.

As you become better, you're allowed,

you're able to breathe better on your own

and the machine does less and less work.

Unfortunately your lungs

aren't gonna get better.

So the act of putting you on the machine

is almost a futile effort.

The machine is there to help you and then when you

get better, we can take the machine away gradually.

What's gonna happen if we put you on the machine is

that you're not gonna get better.

This is you, it's sad and it's frustrating

and it's anger-provoking but your lungs

are about as bad as they can get.

It tells us from your breathing test,

you know the breathing test?

Not the little aerosol thing but

the breathing test on the big machine

and our blood gases that we do,

that tells us what you're like

and what your body is telling us

is that your lungs don't have much left.

They've been working for 81 years

and now they're working overtime.

- 83 years. - Yeah, 83.

- Well--

- I think your decision of saying that

you don't want to be intubated, I just,

I think that's a good decision for you but

I don't think you understood what intubation was.

All right, it's the act of putting that tube in,

into your throat and attaching you to a machine.

Now if anything should happen that,

the only reason we would do that

is if you got worse than you were,

remember how bad you felt yesterday?

If you got worse than you were yesterday,

worse, if you can imagine feeling worse,

we'd think about it very seriously and if we

waited too long or things got even worse,

your heart might stop

because without the oxygen in your heart,

your heart doesn't go.

You know that, without oxygen

in your heart, your heart doesn't go.

If your heart doesn't go, your brain doesn't go

and those are the kind of things that we

have to think about, things to start your heart.

But if we don't have that tube in,

it's not gonna really help us much to have

your heart going because your heart still

isn't getting the oxygen that it needs.

So that's why we talk about the heart,

the shocks and the medicines and the tube at the same time.

One hand washes the other.

You can't have one without the other.

- It's like the old saying, we need each other.

- Right.

- We need each other to survive.

You need help, I have your help.

I should help you. - Right.

But what I wanna do is help you.

I want to help you.

But I only want to help you

in the manner that you want to be helped.

I don't want to do too much for you.

- That's the problem.

- I don't want to do more than you want me to do.

I don't want to keep you alive unless you like living.

- That's fine. - Okay?

That's what I want.

- This isn't your body, this isn't your body.

- Right.

- [Patient] Your favor.

- We're asking you, we're telling you what we know.

We're educating you about we know about your body

and asking you to make a decision,

taking how you feel

and what we inform you about

what's going on with your lungs.

I would think it'd be wrong to tell you

that we would put you on the ventilator

and then be able to take you off

because I don't think that's gonna happen.

It may but it probably won't.

The history of people like you

tells us that it won't be easy

if ever able to take you off the ventilator.

- I have two grandchildren.

Two of my eldest ones,

they'll be in Chicago, they're doctors.

Chick Dawes and Mark Dawes, John Stuart's boys.

We just met his sister, the older sister, I saw her

and they were there and they said

we'd see if the physics get better.

I says "I hope so." - That's right.

That's why I think it's good.

I mean you have to talk about this with your family.

It's something you owe them and they owe you.

To listen to you talk about how you feel and how you

want the rest of your days to be.

- I want to be with 'em. - All right.

Do you want any more explanation about what happens?

- No, no. - You know.

- I'm not gonna bore them with that information.

- If they want to speak to anybody, Dr. Jones,

Dr. Taylor and myself, we're all here.

So if you need any explanation or if they

don't understand something, have them talk to us.

- You work in the hospital?

- Yeah I work here, I'll be here 'til seven.

Okay?

All right, it's a hard thing to swallow, you think about it.

Okay?

Okay.

- Mr. Festal.

- [Nurse] Sometimes spontaneously

he will open and close his eyes.

- But not in relation to-- - No response.

- We're gonna take a look in your eyes.

- That's not an uncommon thing, you see that.

- [Nurse] And they roll back and forth sometimes.

- [Doctor] He's responsive, small but responsive.

- [Doctor] Yeah, it's sluggish but responsive

but he doesn't have a corneal stimuli.

- [Doctor] So he has brain stem.

- [Scott] Which is why I say that--

- [Doctor] I'm gonna turn your head there, Mr. Festal.

- [Doctor] See how they move back to midline?

- Yeah. - When they turn.

That's doll's eyes. - Positive doll's eyes.

- Mrs. Paulette, good morning.

Mrs. Paulette, how are you doing dear?

- Spontaneous cleave.

Posturing.

(patient moaning)

- Good morning, can you open your eyes and look at us?

That better?

She may not be long for this world.

Mrs. Paulette, we're gonna take

a listen to your heart and your lungs.

- The sense I got from the family was that

they appreciate the fact that he is not gonna survive.

They want us to continue to support him aggressively but

they want to make sure that he's comfortable.

So I think you have to temper whatever you do with that.

I think that a lot of what we're doing now is more giving

them another day or two to cope with what's happening.

- What they said when they left yesterday was

"Please try to save him but don't let him suffer."

And that's why I said reversibility is

I think the only indication for any pressures.

- It's just the fact that today we

don't feel any of this is reversible

but they're not quite ready to say it.

- They also, just to pass on this information,

do not want to be called if he deteriorates in any way.

They can't handle that anymore.

They only want to be called if he dies.

- Spoke with him and he was alert and with her.

- He's alert and with her now

and I think he still wants to go ahead.

It's just that I, I just have the feeling we're not--

- Doing him a favor. - Well,

I mean we can keep doing this but I think that

we'll probably be able to drag it on for a couple weeks.

But that's all right, I think if that's

what he wants, I don't have any problem with it.

It's just that I want to be sure that that's

what we want and I also want to be sure that

we get the cardiologist here and make sure that

we really are doing everything that we can do.

- [Bill] They know him from recent admissions,

so any one on the crew would be fine.

- 10 of 'em appear to tell us we've done everything.

All right, thanks Bill.

- Med care.

Yes, this is her.

- How you doing? - Oh good.

- Tory? - No, this is Susanne.

Mary's coming along.

- Time for this situation here.

- We're killing him I think.

We're kidding ourselves if we think

that these meds are helping him.

The guy would be just the same if he wasn't on 'em.

- He'd be just the same.

But he's not getting better? - He really would, no.

- No matter what. - I'm not seeing he is.

- Kinda be better to get him out of the hospital.

- Exactly. - Get him out--

- We are not doing one, I bet if we put

a swan in and checked all his numbers,

they'd be exactly the same as when they were--

- A week ago. - Without anything.

- Yeah, I agree.

- It's really funny, I haven't been here

since we put the swan in Friday night and it's

unbelievable because you have such an objective,

you come here and you say what has been done?

And we've come full circle with this guy.

Like I mean when we put the swan in,

it was because he had a fever and it's like

nobody ever mentioned anything about the fever.

What happened to that?

- The fever's gone, not an issue.

- No sepsis.

- The thing is he's one of these guys with

end-stage cardiomyopathy, you can't do anything.

You might as well get him out of the ICU.

Take him off all these drips

before something's gonna happen.

- I think we're being really mean.

- Did he keep going into failure at home?

- He had only been home for two weeks.

He had been at the grade two rehab for

most of the summer after all his heart surgery

and so he had a little bit of dietary indiscretion at home.

He had a field day with Kentucky Fried Chicken and pasta.

- Oh gee, poor guy. - I know.

He's very brittle.

I bet he wishes he'd never done that.

- Had the chicken. - Yeah.

- [Scott] Can we listen to your heart and your lungs?

- Go on. - Good.

- [Scott] Just under this, we're gonna listen

to your heart first and then we'll sit you up.

- [Mr. Gavin] Scratch my back a little bit.

- [Scott] You want us to scratch

your back, where do you itch?

- [Mr. Gavin] Just up top there and in between.

In between, over a little more, that's it, yeah.

- Good. - That's wonderful.

Get the doctor to scratch my

back the first thing in the morning.

- What can I say?

Let's just take a listen here. - All right.

- [Doctor] What's the long term goal here?

- Well I mean the long term goal is he might get better,

he might get worse, he might stay the same.

He sounds like he's slowly getting worse.

- That seems to be. - Yeah.

- [Doctor] It's my opinion too, I just wondered

how long he's gonna stay on all these drips and everything.

Because it seems like he has end-stage heart disease.

- Yeah.

What I'd do is I'd stop most of it

and give him morphine at this point.

- [Nurse] I don't think he would be any different.

- I hate to say it but I don't think he would either.

I don't think we can do anything for him.

But I think he's dying, I think he's dying

and I mean I don't know how long it's gonna take but,

it could take two days or it could take two weeks but

we have nothing to offer him. - I think at this point

the best thing we can do is be as aggressive

as we can be about getting him outta here

because let's face it, the man was home

for two weeks in the last six months.

- [Scott] We're not gonna get him outta here.

- [Nurse] Let's get him so that

he's not hooked up to all this stuff.

- I think what I probably would've done

in the middle of the night last night with

the chest pain is I just would've pushed

the morphine until the pain went away.

His pressure would have bottomed out and that

would've been it but look, we've done everything

humanly possible that you can do here.

We've given him every kind of--

- [Nurse] Every drug known.

- And we know that,

I mean we take a step backwards every day.

The guy hasn't had diuresis over the past week.

So I mean I think we oughta talk to Bill Taylor

and maybe talk to Mr. Gavin about some of this stuff and

I mean I just, I really don't think things are gonna change.

I think if we give him the morphine,

and it may be that he wants us to keep going.

It may be that he wants to sorta keep up

with this because he certainly did before.

He had this near-death experience in

the sick queue where he was in there for two months

and he finally got home for a week and a half.

He may want to keep going.

- When I talked to him in the past, he does.

So I mean I have a hard time

just stopping everything right now.

What I would do is talk to him and the next time

he has that amount of chest pain, just stop everything.

Assuming that the dobutamine and amerno is making it worse.

- [Scott] Just give him morphine for the pain.

- [Doctor] Once you've talked to him about it first.

- [Scott] Oh no, we gotta talk to him.

- But it's also,

there's a medical decision to be made.

Someone can't live forever on amerno and dopamine,

dobutamine, et cetera so you can sort of,

even if he still wants everything done,

you can't live forever on those drugs.

You can sort of start withdrawing one

and then another and then another

and see what difference if any it makes.

It probably is not gonna make that much difference.

- That's the irony of it all is that

you know, he's at the point where

the extra fluid that we give him from these medicines,

it counteracts the effects of any of the medicines.

So you could make a medical argument that

he's better off on none of 'em and just

get a daily Lasix dose.

Well I think we gotta talk to him

and we gotta talk to Billy.

He is DNR, so I think that there's any urgent issues here.

I think he knows, you know,

I don't know if you got a look at him when we walked

in the room this morning but he looked cadaverous.

- Mr. Gavin, what happened last night?

- Well,

I was watching the ball game

and

my

chest started to give me some pains

and

they came in

and

I don't know, they gave me all kinds of medicine

and finally about two o'clock, they left me.

The pain had left.

Now I don't know whether it was angina pain

or what kind of a pain it was.

- [Bill] Can you tell me a little about what it felt like?

- Well it felt,

it seemed to be centralized more

right here in the center.

It was quite severe.

Matter of fact, there was about four doctors here.

- [Bill] What was that like for you?

- It was like the pain when I first came in the hospital.

- [Bill] You mean when you came in a few months ago?

- No. - You mean this time?

- Last

Tuesday. - Uh-huh.

- It was just like

last Tuesday's pain.

So,

they left about two o'clock

and

I

never moved the rest of the night.

I laid perfectly still, the nurse made me

stay still the rest of the night and...

It went away then.

- [Bill] Are you having any of it now?

- No.

I'm pretty good now. - Good.

- There's no,

no pain whatsoever.

- Mr. Gavin, what's your sense of what's going on?

- I really don't know.

Nobody tells you too much. - Uh-huh.

- You know what I mean? - I sure do

and there's a lot of action around here all the time.

- Yes, yes.

- I suspect you have your own sense of it though.

Would you be comfortable letting me hear a little of that?

- I wouldn't mind.

I would like to hear--

- You'd like to hear from me.

- From you or somebody. - Yeah.

Do you have a sense of it yourself in terms

of what your understanding is of what's happening?

- Well,

from what the doctors tell me

now and then,

I'm on the borderline.

I could pass away or I could survive.

They never told me directly one way or another.

- Well part of that I think is 'cause we don't know.

- Well it could be, that's right.

- We have all these sophisticated

machines and equipment and everything

and we can make our educated guesses but

ultimately we don't know. - Yeah.

- One thing we do know over the last few months

with what you've been through with the heart

attacks that you've had and the damage

that your heart has suffered with the surgery

that you had and the complications after that,

that the result of all that is to put you on this,

what you described as the borderline

and with episodes like the one that brought you into

the hospital and ones like the one that happened last night,

it makes us concerned about the possibilities for recovery

and we're not sure, as you said, how it's gonna go.

- Yeah.

- You've given us some directions

about how you want things handled.

Initially when we spoke in the emergency room,

you told me as you had before that you wanted

everything done that possibly could be

and then when we spoke a few days later,

you reconsidered that and spoke with

your wife and your family and so on

and you gave me a different set of directions,

that you didn't want us to do certain things.

You didn't want the tube put back in your throat.

You didn't want to be put back on those

life-supporting machines that you had been on in the past.

- That's right, yes, yes.

I've already signed an agreement with a lawyer on that.

- [Bill] I heard, the so-called living will.

- Yes. - Yeah.

Well you told me about that and your wife did too.

- I think my wife is on the same things as me.

We both went to this lawyer and

that was one of the questions he asked us

about

what do you call it, living?

- [Bill] I've heard it called a living will.

- Living will, yeah.

- That's important but people

are entitled to change their mind.

So the most important thing to hear

is the instructions that you give now.

- [Mr. Gavin] Yes.

He told me at that time that I could change my mind.

- Right.

- So it is possible. - Yeah.

Well you know there are very few people

who could make as informed a judgment as

you can with everything that you've been through.

You know firsthand all the things that happened.

- [Mr. Gavin] That's right.

- So there isn't much question that

when you make a judgment about what to do,

that it's an informed one because you've been there.

It seems, Mr. Gavin, that we're reaching another

point of decision now, particularly with what

you went through last night and with what you're

going through with all these different medications

because it looks like the medications

don't seem to be contributing a great deal

to be helping your heart to function more efficiently.

- [Mr. Gavin] Yeah.

- It's also clear that you can't stay on

medications like this and in this Intensive

Care Unit for an indefinite period of time.

The clear hope and the plan would be that

if we could withdraw some of these, we could see

if you're capable of moving from the Intensive

Care Unit and doing okay in a regular part

of the hospital with a hope toward moving

toward a discharge--

- [Mr. Gavin] Experiment a little bit with the medicine.

- We shy away from the word experiment because

it sounds like we're treating you like a guinea pig.

But I think that we need to see

how you could do without having some of these

powerful medications running into you all the time

and one of the things to consider is

whether the goal is to give you all

the medications and see what that can do

for the heart or to look at the whole picture

and try to think toward what happens.

Can you leave this part of the hospital,

the Intensive Care Unit?

Can we safely move you to another part

of the hospital in the next few days

and can we think about eventually having

you leave the hospital if things go well?

What are the goals for your treatment?

And we have to face the possibility that

you brought up about being on the borderline.

We would hope that things would go well

and that you could be able to leave this

part of the hospital and hopefully that you

could eventually go home, as you were for

a few days before you came back in this time.

But we don't know.

And in the midst of dealing with all that,

we have to have some idea of what

the ultimate goal is for what we're doing

and what I heard from you and your wife

when we spoke the other day was that your goal

was not to necessarily have every available

test, medication and machine but that we needed to

maybe get a little more reasonable about that.

Devote our attention to something maybe more realistic.

One thing that is realistic is your comfort.

We can always keep you comfortable

and we're never gonna forget about that.

Last night in the midst of your pain,

they were walking a tightrope with balancing

the different medications and trying to get rid of the pain.

We do have medications to get rid of pain though

and one of the ways that we could decide

to go depending on how it sounds to you

is to make your comfort our number one priority

and to do things for your comfort,

even if it may mean withholding some of

the medications that we're currently giving you

with all these intravenous drips and so on

that can only be given here in the Intensive Care Unit.

How you feel about that is really key.

- It's kind of expensive too, isn't it?

- Yeah but fortunately we're in a situation where

that's not really something that we have to deal with.

- Yeah.

Is that right, you don't have to deal with that?

- No.

That doesn't enter into the decision-making at all.

- Yeah.

- Is that something that's of concern to you?

- Well naturally it would be, sure.

- Your situation with your--

- This thing ain't gonna go on forever you know what I mean?

- What do you mean by that, Mr. Gavin?

- I don't mean forever, I mean you know for any

real length of time and I'm fortunate enough

as it is now to have the Blue Cross and Blue Shield

taking care of these bills, otherwise I'd be cleaned out.

- Yeah, anybody would be cleaned out

with the bill that gets generated.

But I think fortunately that's something

that we don't have to take into account

right here in making this decision.

- Well that's good then.

- Could you share with me what

thoughts you're having about all this?

- Hmm?

- I said could you share with me what thoughts

you're having about all this as we talk?

- There's different cases in the paper

locally

and

the people are nothing but vegetables,

if you follow what I mean, you know?

They're just

kept

alive through machines and

so forth.

I wouldn't want to be like that.

In other words, I wouldn't want to

not recognize you or my wife or my family

and

that's about,

that's what I consider a vegetable.

- Well the decision that you and your wife

gave me a few days ago, that you didn't want

the machines and tubes and so on is a way

that we can promise you that we can

do everything we can to avoid that.

But that situation usually happens when we use

all those machines for artificial life support.

- Some people, what was it that,

that woman that was on the

diabetes there, her husband.

The case just a couple of years ago.

- [Bill] I know who you mean.

- I forgot what their name-- - Von Bulow.

- What? - Von Bulow.

- Bulow, yeah.

You wouldn't want to be like that, you know?

- [Bill] Yeah.

- And that's what I'm considering.

Because you always pick the worst case first.

- [Bill] Yeah, I understand.

And fortunately those worst cases are pretty unusual.

- Yeah.

- But it's not that unusual in

a hospital like this to have some cases

that may not be that extreme but that are

also very difficult and situations that

I think some people wish they hadn't

gotten into by the time they were in it.

Not only the people but their families and so on.

- Yeah.

- So that I think although it may be difficult,

having this kind of conversation ahead of time

when you're capable of having it will help

do everything you can to prevent that kind of situation.

- Well in a case like that, Doctor,

it would depend upon the case, you know?

Maybe we were too,

too...

Too quick in making a decision on that,

on something like that, you know?

Because we made it down in Florida.

We drew the will up down in Florida.

- Well one of the things that I mentioned to you

a couple days ago when you gave me your decision

then is that these things can always be changed.

- Oh, I know that.

- So you think about it as you

talk to your wife and your kids.

What you said a couple days ago

doesn't have to be what you say today

and whatever instructions you give to me

and the rest of us here are the ones we'll follow.

- Yeah.

In other words, do I have to give you a decision today?

- Not necessarily but I think that we need

to continue this conversation because the current

situation with all these powerful medications

that can only be given here in the Intensive Care Unit

is not something that can go on and on and on.

I think one of the decisions that we're facing

is do we see how you would do on fewer of these medications?

- Sure.

- And to do that might mean really making

a new goal for your treatment and the goal might be

that we're gonna try to have you on as few

medications as possible so that we can think

toward getting you out of the Intensive Care Unit

and we're gonna maximize your comfort above all else

and if we do that, we have to understand that we're

taking a risk because it's possible that some of

these medications may be doing something to improve

the functioning of your heart and that without them,

it may be more dangerous.

You talked about being in that borderline situation

where we weren't sure whether you were gonna survive or not.

It's possible that withdrawing some of

the medications could jeopardize your survival.

It's not something,

it's not a step to think about lightly.

- I really don't know what to

tell you right here, not here and now.

- In the past when we've talked about things like this,

you've wanted to talk it over with

your wife and have us talk together.

- Oh yeah because it's a big decision to make.

- She's gonna be in a little bit later.

Would you prefer to have me come back

and we can talk when she's here?

- Beautiful.

- All righty, let's do that.

- Because maybe what she can't think of, I can.

- Yeah.

- Or I can't think of, she can.

Which is mostly that.

- I think it works both ways, Mr. Gavin.

All right, well I asked her to give me a call when she

comes in, so I'll come back and we'll all talk together.

- Okay. - All righty.

It's good to see you. - Fair enough.

- [Bill] I'll be back later to see you.

- [Mr. Gavin] Okay.

- The issue is how intensively should

he be involved in the decision-making

and if something's a medical issue like he's not

responding well to anatropic meds that he's on,

isn't it a medical judgment that they're not working well?

- And should it be presented to him that way?

This is what's happened, you've been

on these meds for such-and-such number

of days and they're not working and I think

we need to talk about, I mean I don't

need to tell you how to present it to him.

But there's a fine line about

where his responsibility ends. - Yeah, absolutely.

- And our responsibility becomes more.

- And even in this case, it's gonna be more us.

- It certainly is. - Yeah.

- The angina is gonna worsen his heart function

and cause him pain, worsen his heart function

and make him have more pulmonary edema.

- I think just by virtue of the fact of

the amount of IV fluid that he's getting

with all these different drugs is making him worse.

I mean if he weren't getting all of this IV fluid,

I think that we would be able to stay on top

of his diuresis a little bit better than we are.

- I don't think there's any question.

He doesn't have to participate in the medical

judgment about how we're gonna minimize

his angina and maximize his cardiac output.

But it is a fundamental reorganization

or reorientation of what we're doing if we say that

comfort above all else is the criteria by which

we judge everything and I think it would be

fair to have him and his wife involved in that.

But he would've been treated differently

last night if that had been the goal.

He could conceivably be treated differently today

if that's the change that were made I think.

- [Doctor] So where is he at this point?

- He wants to mull over what we just talked about

which is this sorta stuff and he wants to wait 'til his

wife comes in and we'll talk some more a little later.

I actually spoke to her a few minutes ago

and she said she's coming in soon.

We'll pursue it then.

- So as it stand now, we'll just continue everything?

Okay.

- Well, not necessarily.

- [Doctor] Start taking off some off the inotropes?

- Yeah, I think that you know--

- You think that's reasonable to do?

- If it's clear to everybody that they're not

doing any good, that they're potential harmful,

then we oughta move, I don't think,

as you said, he doesn't need to make that medical call.

But in the meantime we'll treat him,

focused on his cardiac output and his ischemia.

- [Female Doctor] Until maybe he comes to terms

with the fact that comfort is the way to go,

I guess we could put him to back where he was.

- [Doctor] Yeah, I think so.

- I wouldn't go above this. - No, absolutely.

And he's said that, he doesn't want to be intubated,

he doesn't want to be back on a respirator.

He doesn't want to be reconsidered for surgery.

So all that helps in terms of the degree of

invasiveness that we're gonna subject him to.

- Okay. - All righty.

To be continued.

- Dr. Morgan, answer page on line five.

Dr. Morgan on line five.

(chattering)

- [Nurse] X-ray, room seven.

- [Nurse] Gonna give you a little more John, okay?

- All right.

- Give you some, we'll wait a few minutes

and then I'll give you some more

until you're feeling a little better, okay?

A lot better.

- Mr. Gavin, it's gonna be a few minutes for that medication

to take effect and for you to feel some of the pain relief.

I'm gonna step out and talk to your wife

for a couple of minutes and then come back in.

- All right.

- Hopefully you'll be feeling better soon.

- Okay.

- None of this is good news with all that's going on.

Last night was more bad news with

the long episode of pain he had then.

It looks like all the medication that he's

getting is really doing very little to improve things.

- He's got that shot of morphine,

you don't wanna fall asleep.

- Yeah. - He seems to be fighting.

- Well also I think,

what's your sense of things?

- Oh, I don't know.

I've been just hoping that something would break and

everything would be fine, it don't seem to be today.

- [Bill] No, it doesn't seem to be.

- Yesterday I thought I had a little hope.

But today again, it don't seem to be any better.

- I share some of that, it is discouraging.

There's always reason to hope.

We never can predict the future for sure but

it's looking worse and worse as more of this is going on.

I'm coming to the opinion and I think the doctors

here are sharing it with me that a lot of the medications

we're giving him are really not accomplishing much

in terms of improving the functioning of his heart

and I think that if he is gonna be able to manage,

he's gonna have to manage without those medications since

those can only be given here in the Intensive Care Unit.

My sense and the sense of the other doctors here

I think is that the thing that makes sense is

for us to withdraw some of those medications

and do everything we can for him,

especially devoted to his comfort.

- [Mrs. Gavin] You don't think that he will come around?

- I don't know, I think that--

- [Mrs. Gavin] You're just hoping, we're all hoping.

- We're hoping and we'll see.

I mean he's got a lot of strength,

he's fooled us in the past.

He's come through things that we never thought he would.

- Yes.

- But I think more and more of these episodes

make it less and less likely that that's gonna happen.

But I think it's important to

realize we don't know for sure.

- You think now he's going downhill?

- That's what it looks like.

- It's sad because he has his mind.

I don't know what'll save him.

Just hope.

- We'll do that together.

- All right.

- When he's feeling a little more comfortable,

we'll talk with him about this.

Are you going this way? - No, I'll just stay here.

I feel terrible. - I understand that.

- Because this last,

well he's been, it was good the cardiologist was

right here on the floor when he had that other attack.

It was kind of, you know, they came right in.

I know they're doing everything they can but

it just don't seem to be enough for him.

Well,

do you think he'll go to sleep or shall I stay here?

- I think it's good for him to have you nearby.

What do you think?

- The boys are here too, they're downstairs.

- When they come back up, maybe we could talk as well.

- All right, I'd like you to talk to them, I really would.

I don't know what else to do.

Just hope and say a prayer for him.

He's gone through

an awful lot. - He sure has.

- It's gonna come to an end I think now.

- Have you and he talked about that?

- [Mrs. Gavin] No, he didn't say

anything today when I came in.

I said "Did you talk?"

And he says "Yeah, I was talking about,

"Dr. Taylor was talking about keeping

"me alive on machines," he said.

- How do you think it would be for him

if you and he talked about the possibilities,

including the possibility that he might not make it?

- I always feel that he is going to, up to now.

What do you think?

- Well I have the sense that it's on

both of your minds and that it might be better

for both of you if you could share that,

but it depends on what you're comfortable with.

- Yeah, I don't want to talk about it, I really don't.

- Would it be something-- - I don't know when,

he wouldn't either.

- Would you want me to bring it up when you're there

and see if he wants to talk about it with us all together?

- Sure.

But I don't want to bring it up.

You know, it's a touchy subject too.

- It sure is. - It's a touchy one.

When the boys come up, maybe we can talk.

- Okay, let's see if he gets a little more comfortable.

- Would he be asleep with that morphine?

- We don't know. - You don't know.

All right.

I don't know what else you can do, it's up to you.

- You know you're doing a lot too by being there with him.

I'm gonna go help them. - All right.

- [Bill] The Coordinator will call you when

your sons come back and I'll come back and we'll talk.

- Okay, they're only gone down for coffee.

- You let me know when and I'll be back.

- I'll be here. - Good.

- Bye guys. - Bye.

(electronic beep)

- All the medications that we've been giving

in this Intensive Care Unit, kinda doses

have not been improving the functioning of his heart.

So that I think, you know we never can predict

the future for sure but he said it to me this morning,

he said he's on the borderline between surviving and not

and each one of these episodes that he has I think

makes it a little less likely that he's gonna survive.

He's a very strong man though.

- He's been through a lot, he's been through a lot.

- And he's fooled us in the past too

when we didn't think he was gonna make it.

So I think we have to be humble about our ability to

predict the future.

But one of the things that I wondered and I

spoke with Mrs. Gavin about it a few minutes ago is that

sometimes when everybody's aware of the issues about

is he gonna survive, isn't he,

that it might help to take away some of the barriers between

you folks if that's talked about in the open.

Different people are different.

Some people would rather not do that,

some people would see it as throwing in

the towel and giving up, which we're not doing.

We don't want to give him the wrong message.

But on the other hand, it's on your minds, it's on

his mind and if it would allow you folks to talk about it,

I think it would probably be good for people

to be able to share their concerns because

I think he might feel that support.

If he knows you're thinking about it and he is,

maybe to be able to talk about it together

would be something that he'd feel good about.

If he's more comfortable after the effects of the morphine.

- Yeah.

- [Bill] Take your time.

- Gosh.

I don't know what we will do.

- [Son] The life support.

- Would it go as far as that? - A life-support system?

- He's already given us very clear instructions about that,

that he didn't want life-support systems

in terms of tubes and machines and so on.

He doesn't want his heart restarted if it stops.

He doesn't want a tube put in to breathe for him

if he's unable to breathe on his own

and I think frankly that that's a wise decision

because if it reaches that point where his heart does

stop as it has in the past or if he's unable to breathe,

I think the likelihood of him being able to have

a meaningful recovery after that is so small--

- Next to nothing. - Yeah and it really would be.

- What are you doing now Doctor as far as reviving

when he's having these pains and everything else?

- [Son] Do you just stimulate him enough

to get him going again?

- We're actually not stimulating.

We're giving him morphine.

The primary action of that is to relieve his pain.

But there is some reason to think that it

also helps his heart to function more effectively.

So if we can get some more effect that way,

we're delighted to have it but we're

focusing our attention on his comfort.

One thing we can do is prevent him from being uncomfortable

and the morphine is the best way when he's

having the pain that we can accomplish that

and if it has other benefits, so much the better.

But I think our primary goal at this point is to

do everything we can to keep him comfortable.

- But he did say he didn't want to be on anything.

- He's been pretty specific. - On several occasions,

he has said this in the past.

- [Son] And there really wouldn't be much point to it,

his condition the way it is. - That's right.

- He's made it pretty clear, he doesn't--

- We all feel pretty much the same way really.

- And he hasn't walked for over a year and he said

"I don't think I'm gonna be able to walk anymore."

He says "With this heart condition the way it is,"

he says "I'm just gonna be in a chair and that is it."

I said "Oh, don't feel like that."

I says "You're liable to

"come around and start walking, you never know.

I don't know, so.

He's got to the point where he feels

that he isn't gonna get up again.

- [Son] He knows his condition.

- That's why I wanted to boys to talk to you.

- When he is more comfortable, do you want to speak

with him alone or would you like me to go in with you?

- Yeah.

He'll be asleep awhile now but they can page you.

- [Son] Would you like to wait?

How long you gonna be here, Doctor?

- I'll be around for a little bit.

- [Son] Would you want to wait until Jack comes in?

- Yeah, I think-- - Yeah.

- Why don't we do that? - Yeah.

About what time will you be here 'til?

- Until about six. - Oh, he'll be here.

- He'll be here probably 4:30, five o'clock.

- [Mrs. Gavin] So we'll wait around and we'll talk to you.

- We'll let dad sleep for a little while.

- Okay. - All right?

- [Mrs. Gavin] All right.

- And we'll wait for Jack to come in and then we can talk.

- When he comes, would you like us to page you?

- It's up to you. - Sure.

I'd prefer to have you talk to him also.

- He knows the ramifications, he knows everything--

- He knows everything firsthand.

- [Bill] I misunderstood,

I would like to get to talk with him.

Whether you want me to be in the room when you

speak with your dad or not would be up to you.

- Sure, that's fine. - That's fine.

- [Bill] All righty, so I'll be around

and you give me a buzz when he arrives.

- [Son] All right.

- All right, thanks Doctor. - Thank you, Doctor.

- [Doctor] The problem is if they lose bowels,

the main bladder, they lose function all over.

- [Nurse] Okay.

- Well that's probably what it is.

She told me to,

I don't know, it seems like

when I talk a little too much, you know?

- Yeah, even the exertion from that probably is a lot.

- Yeah.

- He says "Am I talking too much,

"that's causing all this exertion?"

But I don't know.

- Well,

looks like an

experiment.

When my boy Jackie was in last night,

after he left,

that's when I had the

little attack again. - Uh-huh.

- And

it seems that

that's what it was I think.

I believe that was,

He left about 7:30

or eight.

You know?

- Would that exertion do it?

- [Bill] Well it's hard to say.

We'd have to wonder if, but it seems to be related.

I think it's possible that it's not related though.

It may be that these things just happen and we look for--

- I know. - Reasons to try to figure

it out and sometimes we hit on them

and sometimes it's just a coincidence.

We don't really know, I guess that's

one of the main messages is how little we end up knowing.

- Yeah.

Because

you see,

well you and Tommy were in the room around when,

around noontime wasn't it? - Just about noontime, yeah.

- Yeah. - Yeah.

- It seems that--

- [Son] Shortly after that you had another one?

- Shortly after that, yeah.

So I don't know.

- [Mrs. Gavin] I don't think they talk that much.

- It's hard to pin it down. - Yeah, it is.

I suspect that some of the talking

is probably very good for you.

- Stretch those vocal chords.

- [Son] Do some yelling.

- There was awhile there you

couldn't talk at all, remember?

- Also to get some of the positive stuff

that comes from having your family here with you.

- So you were gonna ask him

about the machines and everything.

- Yeah, I think we've been through that.

I understand pretty well I think, Mr. Gavin,

your instructions about what you wish

for us to do if things are to get worse.

If your heart should stop, if your breathing should stop,

you've given pretty clear instructions that you don't want

tubes and machines and all the things that you went

through a few months ago when you experienced all of that.

- Yeah.

- I don't know that we need to bring it up again

beyond that unless you feel that there's something

different or that you've changed your mind about things

and if you ever do-- - Oh no, it's just that

I thought once it was

pinned down, this thing, you know

with the lawyer that

that means I have to go along with it.

- That's not true.

- Well you've,

you've changed my mind on that then.

- You can always change your mind.

We'll go by whatever you tell us, even if it's

something different today from what it was yesterday.

Even if it's different from what you thought

when you signed that living will with the lawyer.

Whatever you tell us is what we'll go by

and you're entitled to change your opinion,

change your instructions to us and whatever you tell us,

we'll listen to that and follow your instructions.

Have you thought about changing your mind, Mr. Gavin?

- Have you thought of anything?

- Have I thought of anything?

- Have you thought about changing your mind?

You just said you want Dr. Taylor

to do whatever he thinks is best.

- Well no, the way I was explaining it to Dr. Taylor,

because I took

the most severe cases.

You know, the

Von Bulow and...

And

well there was a couple more too that were

not quite so big.

But

I just assumed all along that

because the other ones, they were...

But

we don't have to,

don't have to take the severest ones.

- No.

You feel like you want Dr. Taylor

to do what he thinks is best for you.

- What you think is best for me,

I'll go along with you Doctor.

- Well I think at this point Mr. Gavin,

given all that you've been through,

given the episodes of pain that you had last night

and today and given the failure of the medications that

we've used to try to improve the functioning of your heart,

that what's best is probably

to try to see

how you will do without some of these powerful medications

that are making some of their own complications

and in the midst of the changes as we

try to see if we can turn down or even

turn off some of these powerful medications,

to do everything we can above all else

to make sure that we keep you comfortable.

- Well that's the main thing.

- We don't mean to be puttin' it all in your hands.

- [Bill] It's fair for us to share it, I think.

- All right.

But you know Dr. Taylor will do what he can for you.

You know Dr. Taylor will do what he can for you.

- [Mr. Gavin] Oh, I know that.

Definitely. - That's a vote of confidence.

- [Bill] We've been through a lot together, Mr. Gavin.

- Yeah.

- [Bill] It's been a very long haul for you.

- [Mrs. Gavin] Well you never know,

he might be up and around before you know it.

- [Bill] We don't know how to predict the future.

- [Mrs. Gavin] No.

- [Bill] And we've been,

we talked about that earlier, I talked about that

with your family, we've been surprised before.

You've come back from situations that

nobody ever thought that you could.

So we have to be humble about predicting the future,

as we talked about before.

But as you said to me this morning,

you're sort of in a borderline situation now

between surviving and not surviving

and I think that your bringing that up

is something that we shouldn't run away from.

At the same time that we acknowledge that

we don't know what's gonna happen and that we

point out that you're a man of great strength

and that you've fooled us before in terms of

your ability to come back from situations

that we didn't think it was possible.

I think it's important that we acknowledge

what all of us are afraid of too

and what we're all thinking of as a possibility.

Because sometimes if we don't acknowledge

the possibility that you mentioned this morning,

not only the one that you might survive and be up

and around but also the possibility that you might not,

sometimes that can be a barrier between people.

Even between people who love each other a lot.

If you're having a thought about what might happen

if you don't make it and your wife's having that thought,

sometimes it's too bad if people

can't talk to each other about it.

- Well that's true.

That's true.

Of course you know as you say

Doctor, this

living will fools a lot of people.

- How so? - Especially

people that,

in a category like us, I mean

we don't know too much about it really.

I don't, I know that.

- Well it's interesting for you to say that,

Mr. Gavin because I don't know many people who know

more about it than you do with what you've been through.

You know firsthand what-- - That's true, yeah.

- All those things are like in a way that most of us never

experience until we're in the midst of it.

You've already been there. - Yeah.

- So you know very much what those different things are.

- Just hope and pray everything shall be fine.

We won't have to worry about those things maybe.

- Well that's just one of the

things that might run in a way I don't want.

- I hope I don't.

- [Bill] I hope you don't too but I have a sense

that the two of you and actually maybe all of you

have some things to talk about that if you wish to.

- Yeah. - That's up to you.

Because I have a sense that there are some things

on your mind not only about the hopeful things

because we all have hope but also some of the concerns

we have if what we're hoping for doesn't happen

and one of my hopes is that you folks

get a chance to talk about that with each other.

- [Mrs. Gavin] Okay, we will.

- You'll do what's right.

Mr. Gavin, I'm gonna go now and leave you with

your family together but I'm gonna be back in the morning

and in the meantime folks here know how to reach me.

- Yes. - All right, Doctor.

Bye bye now. - Good to see you.

- [Nurse] Do you need anything?

I'll be outside, okay? - All right.

(chattering)

- [Scott] Anyway he's, he's looking good.

- So there's, this is it.

- Oh yeah. - Yeah I mean, we're not--

- He's DNR, I mean he understands what the situation is.

Why don't you just come right out and say it?

- No, I just assumed.

- He's talked to him about it and Bill's talked to him

and he's pretty, I think he understands that

everything has been done.

I think the goal is to see if we can get

him out of here and maybe get him home for,

I mean he's been home for,

what did he get, two weeks?

I guess he didn't even get two weeks.

Two weeks out of the hospital in a rehab hospital.

He's never been home since he had to operation.

If we could get him home at all, it would be a victory.

- Is he,

he's on procaine, can he use IV antiarrythmics or

how DNR is DNR?

- Well yeah, no I mean anything

pharmacologically you wanna play around with is fine.

- Okay.

- But I mean I don't think,

his activity has not been a problem.

- [Doctor] No.

- Power failure. - Power failure.

- Power failure has been the problem.

- And chest pain. - And chest pain.

But he, you know,

I think basically what we've decided to do is respond

to the chest pain with morphine and nitro rather than,

and at this point I wouldn't put him back on IV nitro.

I would just give him morphine and the paste.

We're not gonna escalate this thing again.

The guy's been through enough.

But that's not gonna be an issue today, he's looking good.

We may get him to the floor.

- [Nurse] I'll come back and get all that stuff.

- My glasses are over there anyways.

- [Nurse] Yeah, do you want them to come with you now, or?

- [Mr. Gavin] No, I should have them with me

at all times because I'm as blind as a bat without them.

- [Mrs. Gavin] Do you wanna take your applesauce with ya?

- I do not want that stuff. - No applesauce.

- [Nurse] Absolutely not.

- [Mr. Gavin] I did not order the applesauce

and whoever took my dinner did not want the applesauce.

- I did. - You took my dinner?

- [Nurse] No, she wants your applesauce.

- I ordered the applesauce.

- [Nurse] Why don't you take the applesauce?

- I don't want it. (laughs)

No way, I just thought maybe he would have it.

- I'd love you to have it. - I bet when we get down there

he's gonna be calling me up on

the phone looking for his applesauce.

Okay?

- Yep.

We're all set, gimme that too.

- Can you hold your chart for me?

- Yes, put it right in there. - All right.

- How's that?

- Is my handkerchief around here?

- Yeah, I threw it in your bag

because it kept landing on the floor.

That's it.

- [Nurse] See you later.

(electronic beeping)

- The same problem that we had with

the Wong family and this person was brain dead.

- He's not brain dead though. - I know he isn't but--

- [Nurse] If he's legally brain dead,

the tube comes out and that's it.

- Well that wasn't with the Wong family.

The patient was legally brain dead

by all criteria, by all the Harvard criteria

and we kept the patient on a machine,

basically kept the heart breathing for three days

until the family could deal with it and even

after three days, they couldn't deal with it

and when the two did come out, they blamed me.

I was the culprit, I killed their mother.

- [Nurse] They said that to you?

- Not directly to me but because I was

the most visible person and you know, it' hard.

It really is hard when people try to blame it

on you because you know, the inevitable happens.

We have no control over the fact that their mother is brain

dead and I guess it's all in the way you look at death.

Whether you look at it legally or emotionally.

- That's a very hard concept I think to understand,

brain dead, I think that's-- - It is.

- That's where you get into the problem of

providing too much information to families and like I said,

it's just a difficult concept. - We shouldn't say brain dead.

What we should say is that your family member

has passed away and the only reason you see

a heartbeat is because we're artificially

keeping the body essentially

going, keeping the heartbeat going because of oxygen.

Because the longer that we procrastinate

in that particular instance, the longer that we keep

the person's heart beating, the more confused

the family is gonna become and if you tell

the family on a Monday that your mother is brain dead

and three days later, they're still quote

alive in the bed as far as they're concerned,

then obviously they have hope and they start to question

whether it is in fact true that she is brain dead.

- Why do, just to talk about this and then

to get back also to this situation which

you're gonna have to live through this weekend,

I mean that's the other piece of this

and what does that feel like to live through this?

But why do we get into saying that anyway to families?

That's really the issue, why do we do it?

- I think to protect them, I think to make it

easier for them I guess is kind of the, it's difficult--

- [Nurse] To make it easier for them

or to make it easier for us? - Maybe for us.

It's difficult to say to someone,

I mean maybe it gets into how you really look at death.

Is the person, I mean you're in there

turning the person from side to side.

You're doing AM care but yet the person is supposedly dead.

- I think also to get everyone in

agreement that that is in fact the case

that someone's dead is another difficult thing.

My understanding is neurology

wanted to correct the sodium.

- [Nurse] Yeah.

And actually--

- But then you start getting various--

- That was to supply criteria though.

You know, they wanted to supply

the criteria for brain death, you know?

Not febrile, da da da da da, not hypothermic

and he wanted, evidently it was a case

of electrolytes being not in balance.

- [Nurse] But even after they were, the family

still didn't accept it, they wanted a fourth concept.

- But don't we tell, should we tell families that?

Because we involve families in the whole decision-

making process and the whole plan and from my experience,

they're involved much, much more

here than anywhere else I've worked.

I'm not sure more than they should

but for sure it's more than most.

- In some cases, it's more than they should.

We're giving them, we're allowing them to make

a decision that is not, that they know nothing about

and we're not informing them of what exactly is going on.

- Well I think they are being informed but it's

what they can process, I mean all the terminology.

We went to school four years for us to understand this.

I had a hard time when I first came here with brain dead,

I'm like yeah but the heart's beating.

Well wait a minute, but they're really dead?

And then when I learned about the Harvard criteria,

I even had a hard time and I'm a nurse

and I'm sure the families have a hard time

in a one hour conversation with the docs just saying "Yeah,

"he's dead and we're gonna take the tube out and that's it."

But like, wait a minute.

- I can understand that completely and that night

logically I could understand all the steps that

they were going through but it's very difficult

when you give that much energy to have basically

a family member put the blame on you essentially.

To say to you, "How could you possibly want

"to take that tube out, what's your motive here?"

I mean he went to the extent of "Is your motive

"that you need a bed in the Intensive Care Unit?"

- They said that? - Yes, I mean--

- That's awful. - Because they,

but they didn't truly believe that, I understand that.

They really, truly didn't believe that.

The problem was is that they were under so much stress,

they didn't know which way to turn.

It was like oh my god, the day has finally come,

this is the end and I was the most,

as the nurse you're the most visible person.

You're there consistently throughout the whole evening,

I was there, neurologists come and they go

and I was the person that this particular son

decided was the person that he needed to vent his anger at.

- [Nurse] You were also taking care of the patient

who was dead but alive, I mean you were--

- And that's hard to do.

- Adding to the anxiety. - Exactly.

- You somehow add to the confusion when you continue

to take care of someone who they understand is dead.

I think that you're gonna get the heat.

You're gonna get a tremendous amount of rage.

I mean you took care of them, they're dead

but they're alive and now you're gonna end their life.

I mean how do you-- - Right.

- I mean we could talk about it here, it sounds kind of--

- [Nurse] It's not who it's more logical to put blame on.

- Well-- - It's confusing.

- It's confusing, it is confusing but I guess

the question is that we do tell them that way

to give 'em time. - Right.

- We were attempting to make it easier

on the family by allowing them, we essentially

controlled when we let the person go.

They came in on a Sunday and they were brain dead on

a Sunday and we manipulated it by adding stuff, depressors,

she was on Neo-Synephrine to keep her blood pressure up.

Everything was manipulated to keep her going so that

the family could get the consults in and could deal with it.

Now do we make it any easier for that family?

Not as far as I'm concerned because when the end

finally came for them, it was no easier on the Wednesday

than it was if they had dealt with it right then and there.

Go right in and say "We have all the criteria."

We do a CAT Scan, it shows a huge bleed.

We do a flow study to the brain

that shows absolutely no flow to the brain.

We do all the studies that indicate

whether the person is brain dead.

If it's true on a Sunday, then

I mean we didn't make it any easier.

- [Nurse] Did you do all that in one day

but they still wanted a second consult?

- They kept adding consults. - In response to the family?

- Yeah.

- [Nurse] You're not gonna change

the fact by just kinda softening it a bit.

You're not gonna change it.

- For some families you need to look at a framework.

You have to look at the medical assessment,

the Massachusetts State Law, what the criteria are

and I think professionals have to take a look

at their own morals and values before they

enter into each individual situation and you should

try and separate yourself a little bit in that respect

and I think the treatment for the family should be

Social Service and more of an emotional support

rather than basing their loved one's--

- Destiny.

- Destiny, their treatment in

the hospital on the family's emotion.

I mean we're focusing on the family's emotion

and we're basing the patient's treatment on

the family's emotion and now we're talking

about holidays and I don't think that's the issue.

- We give them too much control.

How many times have we talked about,

I mean they go out and ask the family,

I mean a family that doesn't know anything about

medicine at all, "Do you want your family member

"to be put on pressers if they should beat it?"

Now I mean if I was a family member, I would be like my god,

and what you're asking them is to tell you

to deny their family member something that

might keep them going or alive or save them.

- Why are you doing that? - I think it's passing

the buck about who's gonna make the decision.

Nobody is comfortable with the decision.

- [Nurse] It's because you or whoever is involved

is supposed to know the feelings of uncomfortableness.

- If I was in that position,

I would examine my own morals and my values.

- [Nurse] It's the responsibility we have.

- [Nurse] That's not the case in 100% of the times.

- That has everyone zero in on that because I never

saw the kind of involvement with family at other places.

So someone from up above-- - Is it good or bad?

- Is giving this philosophy down to everybody.

That you have to include the family in the decision-making.

- Include them but not let them make the decision.

- I think we need to study and look at how do families

feel who've been through making this decision afterwards,

a few months, a few years after.

I think a lot of times if they don't

have any medical background, we really

put way too much responsibility on them.

- But the thing is that when a physician presents this

to the family, a physician has a very powerful perspective

and I really believe that he can manipulate

any family to believe what he wants to do

and it's the art of experience.

- By his values and what's morally right to him

and where he's comfortable with the whole issue.

- And it's only, let's be honest,

it's only once the decision is

that this person is probably going to die.

Before that point, they don't go out,

I mean that's really when we start,

that's when we go out and say to the family,

"How do you want us to do it, how should we do it?"

- [Nurse] Until then no one has any troublemaking decisions.

- No, we excuse people from the room.

We're involved in something with, you know, with the

person that you gave birth to and we'll see you in an hour.

We don't have then in there.

But it is when they're dying that we do that and I think--

- [Nurse] Nobody's comfortable with it.

- And sometimes we're not present, we're not there

on the phone when the whole talking to the family,

we'd like to put our two cents in but, you know

and it's up to them how they use their choice of words.

- But I've been in a situation where

they've talked to the family, "What would you like us to do?

And the family said "Oh, we'd like

"everything done but we want him comfortable."

So they took that as oh, he's full code.

So I started talking, it was Cindy Frusi and I,

Cindy Frusi and I said well you know, when he--

- [Nurse] Who are you talking about?

- This is a guy a couple years ago.

Cindy Frusi and I basically got a DNR status

on this guy at one o'clock in the morning.

I mean it was just, well do you realize that if he dies,

if he stops breathing, we will shove a tube down his throat,

we will press on his chest,

put big lines in his neck, et cetera, et cetera.

"Oh no, we don't want that."

I said "Well that's what they're asking you to decide.

"When you say you want everything done, that's everything."

So they said "Oh no,

"we don't want that, we want him comfortable,"

I said "Well then that's what you have to tell us.

"You have to tell us that you don't want drastic

"measures taken and those are the big drastic measures.

"Those are things that you don't want to see

"and that you don't want to see him go through."

And we basically said, I basically said,

I forget who it was, I said "Come here,

"please, the family has something to tell you."

Da da da, "They don't want this done."

Okay, we have a DNR order.

- You were there. - One o'clock in the morning.

- [Nurse] Did you call the family back, Jane?

- They were there, they stayed through the night

and we put him on a morphine drip

and he got very short, he was a guy with

lung cancer or something and he was at home

for six months, eight months and they'd taken

care of him and they realized this was the end.

But he was in the ICU because the decision hadn't been made.

He was like this, being intubated

and we basically coordinated.

They physicians weren't listening to what the family

was saying and as you spent more time with the family,

as you spent more time with the family,

you got an idea of where they were sitting

and the physicians were busy.

So that's, I mean that's the role we play.

It was a true patient advocate situation,

patient-family advocate situation including the family,

you know, what really do you want to happen?

You don't come here without dealing with it first.

I mean my first month here was,

I mean I was an emotional wreck

because all my patients died.

I was like what was I doing?

It was very frustrating but then you solve it

and you say these people are better off dead.

They're more at peace,

but it also is the way I deal with it.

My religion, my morals, what I do,

how I live my life, my philosophy, da da da da

and everybody has to do that within themselves

and that's why everybody deals with it

individually and presents it individually.

(patient coughing)

- [Nurse] You need your pillow?

Are you there?

What's too tight?

You were a little better than what you tested before.

- [Doctor] Because we've all agreed that since her

troubles were transient, that intubation was an appropriate

form of therapy in spite of the fact that overall

in the event of death, she's not to be resuscitated.

- Right but I guess my concern is that

she's been intubated five times in six months.

- Yeah but each time with a reversible phenomenon.

Look how much better she is now.

- No, I agree.

- So I think that would still be an

appropriate part of regular care as opposed to--

- So with any type of--

- If we extubate her and then she has a VF arrest,

she's to go but if as part of hypoxia,

we decide to re-intubate her, we'll do it again.

I wouldn't hesitate to do that.

She just has marginal lungs and complicates with either

failure or pneumonia but those are both reversible.

- True but in the broad spectrum of the picture,

she has COPD to begin with, she's now immobile.

She has very poor airway clearance to begin with.

Aren't we talking about a chronic situation?

- We are because she's going to go to

a chronic hospital from here but still

she's entitled to life if she can get it.

- For sure, I guess what I'm actually bringing up is

is there any concern about perhaps traching this lady?

- Oh yes, depending on how reversible it is--

- I guess that's what I'm asking.

I mean is that the only way to protect her airway?

- Well we're not sure that that'll protect it

because even a trach doesn't prevent you from aspiration.

- [Anne-Louise] Surely, surely but

and knowing how he's dealing with things,

if that has to end up-- - We in fact have

sort of started to explore that with him.

- You have, oh okay.

- What his reaction would be I don't know yet

because we haven't come down to the moment

where we've said "Well, now you must make a choice."

- Yes.

So at this point then for any respiratory compromise,

you would want her re-intubated.

- Yeah. - Okay.

All right, thank you very much Doctor.

(metallic clattering)

- Which we did do yesterday. - Let's do this then.

Let's put her on 30%, let's bring her down to four,

let's get a gas on four, see how she's doing and then

we can watch her for awhile and see how she does.

- The problem with her is that she really feels

a difference between six and four and she'll tell you

she's short of breath but her rate actually is

no faster than what it is when she's extubated.

Easier said than done, I mean that's how she breathes.

- What are the plans in terms of re-intubation?

- I'm glad you brought that up because I just had a

talk with Dr. Kerlind about that and his feeling is that,

he just left, if again she has any type of

respiratory compromise unassociated with a V-tach

or V-fib arrest that she is to be re-intubated.

So I said but she's been intubated five times in six months,

are we talking about something more chronic

in terms of protecting her airway?

Because she's always gonna be,

have a poor airway clearance.

She does have COPD, she does have failure.

And he said well he has thought about

the discussion of a trach with Dr. Factor

but hasn't yet brought it up.

But as it stands right now, he would want her

re-intubated for any respiratory compromise.

So-- - Okay.

- That's where we're at. - Okay.

- [Scott] Well but it sounds like we have a plan though.

What George is saying that you know,

we get her off the ventilator,

if she fails again, then we do a trach.

- He said re-intubated, yeah we have to think about a trach.

He's still putting the trach in a very futuristic light.

- [Scott] But I mean that would be the next step.

- Right but I'd rather hit him with it

before she actually gets extubated this time,

being that she may need to be re-intubated

during the night when no one's around

other than those of us that care for her.

- [Scott] But you wouldn't do a trach in the middle of--

- No but that's what I'm saying.

She would get re-intubated and then we'd be

back to having this discussion again without any--

- Plan. - Longer-term plan.

That's all I'm trying to say is that

there's a very good chance of that happening again.

She's doing fine and I think we will

get it dissipated by the end of the week.

- [Scott] It's gonna happen again, whether it'll

happen a month from now or two weeks from now or--

- I think it's kinda cruel to keep putting this little

old lady through being re-intubated all the time too.

I mean that's not a

simple

procedure.

- [Scott] Right.

I don't know, maybe--

- I don't know what his reasoning is.

- [Scott] Maybe he can't make up

his mind whether he wants to, you know,

whether he wants to just call it a day and

not

re-intubate her.

I don't know, I'll talk to him some more about it.

- Okay.

- [Nurse] So I just sense it's really difficult.

I get this old man and he

shows up with these cookies every day.

- You have a call, line five.

Dr. Factor, you can go in and see your wife if you want to.

- [Scott] The thing to do would be to do

a trach if you want to keep pressing on here.

- It's a terribly difficult case, her husband

as you know has

agreed that it would make no sense to do

a resuscitative procedure, on the other hand,

to keep preventing exactly this kind of

thing which is going on while she's alive,

I think it might be worth considering.

But she was the strong member of the family.

She'll have an opinion herself about whether

she wants to do this and she is--

- I think we should talk to her about it

because I think that the pattern over

the last couple of months is pretty clear that she's,

I mean she's aspirated two or three times.

With the stroke, she's just not,

I suppose even with a gastrostomy

which was supposed to be the other thing--

- She already has feeding,

doesn't she have a feeding gastrostomy already?

That just doesn't protect you.

- She can't handle her secretions.

She has no bulbar muscle, so I mean it's gonna,

it may be two weeks

but it's gonna be,

I think we should probably talk to her

about it now that she's got the tube out.

- [George] Well we'll discuss it with him first but

then I think the ultimate decision has to be made by her.

- Right.

All right, well

I think there are a couple of issues.

One is that she failed,

admittedly the long term problem is gonna recur.

Eventually she's gonna re-aspirate,

she's gonna get another pneumophonia

and if she has a trach, then you can treat this.

On the other hand, she may not want a trach.

So I mean I think that

I'll talk to her about a trach right now.

I'd like to get her opinion sort of when George

isn't here and sort of see what, how she feels about it

when her husband isn't here because he's pretty fragile.

So I'd like to talk to her myself about that.

- Nobody ever tells her what's going on,

certainly her husband doesn't, we don't

and George doesn't and she expressed that

frustration yesterday to Sue after George left.

- [Scott] Well George is never gonna either.

- She didn't say anything, she just rolled

her eyes after he had been very chipper in

how good she was doing and all this stuff

and she clearly was disgusted and frustrated.

- [Scott] Now and then I'll catch up with you guys.

- In terms of the plan for the day then,

we're gonna try to extubate again today?

- No. - No.

- We just buff her gases though.

She likes, IMVF6 seems to be a good place for her.

- Let me talk to her first to see how she feels.

Let me talk to her first and see how she feels.

My own personal feeling would be that

I would try to get her gases buffed and try

again tomorrow but I would do it a different way.

I would TP wean her and give her some diuretic

and see if she could--

- [Anne-Louise] In the past she's always TP wean,

she's never been cold turkey.

- I think we've pulled things in a little,

we were a bit abrupt yesterday and that

she went into pulmonary edema in part because of that.

My inclination would be to sort of get her

buffed up today, give her some diuretic

early tomorrow morning, you know,

when she's on sort of four breaths and then--

- [Anne-Louise] Right, we've done on IMP04 and that usually

pulls her longer than an hour once you TP and extubate her.

- Exactly and my feeling would be depending

on what she says today, either

she comes off the ventilator tomorrow and she does okay

and we don't re-intubate her or she doesn't

come off the ventilator tomorrow and she

ends up going for a trach if that's what she wants.

Is anybody else, I mean I think you know,

the thing that makes this case tougher than

some other ones is that George is not free-flowing

with his feelings and he really likes to keep control

of the case himself so that it's much more difficult

to sort of deal with him and say well, you know.

He's not inclined to sort of really open up to her

and tell her, he's more the kind of doctor who's

gonna just sorta do what he thinks needs to be done.

He's gonna go ahead and say "You need a trach."

Rather than "These are your choices."

- [Anne-Louise] I think you just have to take into account

before you speak to her that most therapies

she refuses from chest PT to Albuterol,

I mean everything is no, so you have to think

about that when you're asking her for her

honest opinion of how she feels about the trach.

She doesn't want to do what we do to her

on a day to day basis if you just went by that.

- If that's true-- - A really significant fact.

- Of course it is. - Nobody has ever asked her,

this isn't fair then.

- Who are we doing this for? - Exactly.

- George or her? - That's what I'm saying.

Clearly and with all her admissions,

she's said no to most everything.

But we don't usually give her the choice.

- Clearly she should be able to make the decision

and that's the hospital policy, right?

- [Scott] Right.

- She's certainly with it, I mean she's almost

always with it enough to make those decisions.

- [Anne-Louise] This is not her best time of the day either.

Around 11 or 12 o'clock, no really,

quite frankly it takes a long time to wake her up.

- I'm trying to be a little proactive here.

I'd like to get in there before Kerlind comes by.

He's doing rounds, he's not gonna be up here until 10:30.

So if I can talk to her now and then say to him

"Listen George, she doesn't want a trach."

Then I can take, I'm gonna have to take him on

because he's gonna, he'll give me a lot of crap

about how dare I talk to his patient,

you know and all the rest of this.

- Blame it on the husband. - What?

- Blame it on the husband. - No.

I'm a big boy, I can take care of myself.

- [Nurse] Are you bigger than he is?

- If she doesn't want the trach,

she has to know that the option is

not to be re-intubated every week

and that she's gonna die.

- I can make it clear to her what the options are,

I think I know what the options are.

But I think the thing that jacks up everyone's

anxiety in a case like this is that you know,

got an attending physician who's...

- [Anne-Louise] Who may not agree with her wishes.

- Yeah I mean you know, everything here is

sorta build on Quaker concept of consensus, you know?

So what the patient wants, the house staff wants,

the nurses want, the doctors want and what the family wants

and every time you have difficulty, it's because one of

those elements is out of sync and that's what we got here.

Not from the family, not from the patient I don't think.

Not from the nurses and not from

the staffing unit but from the doctor.

So let me talk to her.

- Still when we, she clearly is

agreeing.

- And as a matter of fact when you pushed

the DNR when she looked like she was going down the tubes--

- I hardly pushed, all I did was ask

and her husband said "Oh, that's ridiculous.

"I wouldn't have wanted you to do that in any case."

But then when I presented that to Kerlind, he said fine.

- [Doctor] I think maybe George will be

relieved if we do it for him. - Yeah.

- [Anne-Louise] Well the one other thing you have

to know in terms of the doctor factor is yes,

he can say "Oh no, I wouldn't want

"you to shock her and pump on her chest."

And he was surprised that it took so long for us

to even bring it up, that's what he said to me.

However when she is short of breath,

his anxiety goes like this.

He drags me in there, whether it's on

the vent or it's extubated and I don't know--

- Right but a morphine drip takes care of that.

- [Anne-Louise] Right, I mean...

- Okay. - Thank you.

Medical Intensive Care, can I help you?

- [Anne-Louise] I think all concentration

is taking the next breath.

I don't think it was anger or something.

- She understood everything in there.

- Oh, absolutely. - Definitely.

And I think it's great. - And Scott was good with him.

He really, he went over everything he talked about

with her and wanted me to see what she was saying

and it sounds to me and it looks to me like she

was in complete understanding of the options

and I did ask her, I said "All the other times, this is

"the sixth time that you've been put on the breathing

"machine, did you want us to do it all these times?"

- I know, I knew how she felt.

- [Anne-Louise] That's why I felt like I had to apologize

to her because I said sometimes we just get overtaken

with treating the fact that you're not breathing well

and we need to do something about that.

- Sometimes he'll go in there and like once she reaches for

the tube or whatever and she looks right at him and it's

like, she just looks at him as if to say what are you doing?

She's trying in her own way to subtly

indicate to him because it's obvious she's

been the strong one and is trying to help him.

- Right. - She's trying to help him

deal with her death, it's amazing.

- And that is the dynamics of their relationship.

I mean that she really has always been strong

and that he is absolutely so devoted

and at a loss without her and to have her

even be like this, to come to see her,

to at least have her be alive is

better to him than anything else.

- I agree, I agree.

- And that's where the problem is gonna lie,

especially if she crumps once she gets

extubated and the choice is made not to re-intubate.

- When she takes a turn for the worse,

I mean is he accepting death when he's running

to grab a stethoscope to listen or the blood pressure

dampened out on the thing, oh my god, her blood pressure and

it's like he wants somebody in there to fix it right away.

- [Anne-Louise] Meanwhile,

he hasn't come to terms with the words,

that he said no, I don't want her resuscitated.

But the event of a cardiac arrest

for Bernice is so minimal.

- That's why he could do it. - Right.

And that's why we got half of what I call a code status.

- But denying somebody a tube is a lot different from

defibrillating them once they've stopped breathing

or their heart has stopped it's totally different.

Especially since he's a physician and he realizes

to his own extent the difference between the two things.

- [Anne-Louise] Correct.

- But I'm glad you said something, that was wonderful.

- Well thanks Sue, I appreciate it.

- I spoke with Mrs. Factor and I've written a note here.

I had a long discussion with Mrs. Factor which

revolved around two areas, tracheostomy and re-intubation.

Mrs. Factor feels quite strongly that she does not want

to have a tracheostomy even though she realizes she will

die if she comes off the ventilator and is not re-intubated.

She's been re-intubated five times in the past two months

and feels that she has been through too much already.

She would also prefer not to have been

intubated at all the last two times

that I have seen her this month.

Given her wishes and the hopelessness of the situation,

I think her wishes are reasonable and will

discuss this with Dr. Kerlind to develop

a plan that incorporates Mrs. Factor's wishes.

She made it pretty clear that she,

as she put it, she thinks George is crazy.

- Is that what she said?

How did she communicate that to you?

I'm just curious.

- She mouthed the words.

I almost cried in there, I tell ya.

I think she's more difficult for me

than this lady, this lady's dead already.

You guys are flogging yourself but just she's gone.

Bernice is a lot harder problem.

A lot harder to walk into somebody's room who's

awake and alert and say "These are the options.

"Life in an institution with a tube in

"your throat on a machine or you can die tomorrow."

She had it much easier.

She didn't have to make the choice.

It happened real quick, she was out.

Just do it and be gone, it's a much better way to go.

I mean look what's happened to her.

She's been around for two months,

the doctor hasn't told her what's going on.

She's been intubated five times.

(electronic beeping)

I had a conversation with Mrs. Factor this morning.

- [George] Yeah.

- She is adamant about she wants that

tube out and she does not want a tracheostomy.

- [George] All right.

Well that's her privilege.

I rather thought that that's what she would say.

- [Scott] She is quite,

you have to know she said that she's,

I think when we re-intubated her

yesterday, she was really furious.

- Before she entered the hospital,

she set very rigid limits to her care.

Limits which were not in her own best interest.

- [Scott] I'm sure that's probably true.

- Always bargaining to accept the lesser

of two therapies and in part that's one

of the reasons that she has been so ill.

Not her stroke, which is major but with regard

to other aspects, both her heart failure

and her chronic lung disease, her overweight,

her obesity and hypertension, always accepting

the minimal amount of therapy and that only

after pushing and compromising and as you know,

her husband or physician was never able to

get her to agree with more than she wanted to

because she was the dominant member of the family.

- Well you know,

I mean I have to say looking at her situation now,

it's probably not unreasonable, you never know what

you'd do in that situation, it's really hard to say.

We'll try again to wean her tomorrow.

- [George] That's the last crack at it.

- Well no, I think you know,

see I'm not so pessimistic in the short term.

I always get 'em off but I mean

I don't know, I can't guarantee that she's not

gonna have, that she's gonna last for along time.

- [George] See the problem is that

she's gonna be left with the stiff ventricle.

- Right, right.

But I'd give her some diuretic before

and if she doesn't want it back in, fine.

- [George] No I mean in terms

of what's likely to happen under there.

- Well I mean it's, you know,

we're talking days, at the best days to you know, weeks.

Because she's gonna re-aspirate too.

I mean I think she made it very clear that

she knew that this meant that she was gonna die.

- And I think she does. - Yeah.

She understood that very clear when I

told it to her and I asked her, I said

"How do you think your husband will feel about this?"

And she said

"He'll accept it."

- But he's having a very hard time living with this.

He came over to my office yesterday afternoon

and he didn't have an appointment,

I said "What are you doing here?"

And I indicated that I knew what was going on and he

says "Well I just wanted to talk to you for a minute."

But I think what he really wanted to know was

did I really know and understand everything that

was going on and I think also he just wanted somebody

to talk to, to feel that somebody knew how he felt.

- [Scott] I think that probably the way to deal with

him is to just say look you know, we talked to her

and this is what she wants, this is what we can do.

We've done everything we can and--

- It'll be, he understands it.

- No, I think he's ready. - He's ready for that.

- Hi.

- As is the family of this man.

- Okay well I don't know him well enough.

Maybe we'll get him off, what do you think?

- The last two days he had been going

so steadily downhill on maximum therapy.

He's been on 60 milligrams of prednisone, on

large doses of

bronchodilators,

adrenergic stimulators.

This has been going on such a long time

and it's like her, a combination of

cardiac failure and chronic lung disease

that I am very pessimistic--

- It sounds like the family,

his family have made it pretty clear that they

did not want super aggressive things done for him.

- Again, there are strong

resemblances between the two cases.

He himself is the strong member of the family.

He runs it and there's a good deal of

resentment among others about the amount

of care and attention that he has required,

particularly with people not blood relatives but to whom

a lot of the responsibility has fallen and it's not easy.

- [Scott] Okay.

- I know how unhappy you are

that the tube had to go back in again.

But I was concerned

that you were getting so tired yesterday

that even

though we could expect good results,

you couldn't do it by yourself.

I also know that this is against your long term wishes

and Dr. Weiss and I have had a chat

about tracheostomy and I've explained to him that you

are a very intelligent and strong woman who has always

known what she wanted to do about her own health

and that your wishes

would be exactly what we would live by

and would be our guidelines.

That's what you want, isn't it?

Okay.

I anticipate

that we will be able to get this tube out

and that you will be able to

breathe the next time without it.

You just got congested

fairly quickly after it was taken out last time.

I think we will do better next time

and you will breathe easier.

Do I understand correctly however that if you should

tire a lot, then you don't want us to put it back in again?

Is that correct?

Do you understand what I'm saying?

Okay, if you should tire

after we take it out next time,

we'll have two choices.

We can either leave it out

or if we think you would benefit by it,

we could put it back in.

All right?

Okay.

Would you want us to put it back in again

if you start to tire without it?

Would you like to think about it

first before we make a final decision?

We've known each other a long time and you can

be perfectly honest in telling me what you want

and I will abide by your wishes.

Okay?

All right, you think about it and let me know.

Let's see if you can breathe against the machine.

All the way in.

All the way in.

Good.

I'll come back later, you think about it and we'll

talk again before we make the final effort to

take it out so we'll understand each other completely.

All right?

Are you tired now?

All right, then doze off and I'll

come back and we'll talk again later.

- Thank you, Dr. Kerlind.

I just want to make sure that you

understand what the options are

and Dr. Kerlind explained them to you very nicely.

If in fact we're able to take this tube out

and take you off of the breathing machine,

would it be your wish to not go back onto it

if in fact you were becoming tired and needing,

needing the support of a respirator?

Okay, that's the question.

Now you've been on it quite a few times so far.

So it's not that you don't know what it's like.

But it's very important that we understand what

you want so that we can abide and go by your wishes.

Being that we're working on trying to get,

are you paying attention to me?

Being that we're trying to understand what you want,

it's so important for what's going to be with you.

I know it seems like everyone keeps asking you

the same questions and hoe many times do we need

to hear it but that's what we do, we like to hear it

to make sure that if you change your mind again,

that we know about it.

Okay?

So I'll let it rest for now.

Okay.

Ask me anytime you want to.

I can understand you pretty well most of the time.

All right?

Okay.

(chattering)

Dr. Kerlind talked to her again.

He couldn't quite get her to have the same

blatant yes-no response to things and he left it

with her that he would get back with her later

in the day and that she oughta think about it.

- Okay.

So... - Okay.

- And I went over it again with her and she's

kind of irritated that I keep doing that.

So I said I'm gonna leave it alone but

I want you to stop us at any time if

there's something you want to know about

or you want to discuss it and we keep

asking you because we want to make sure

because you always have the option to change your mind.

- Right.

- So that's where we're at.

- Okay.

- In lieu of yesterday's events

and after minor discussion with Scott in which he really

felt that the reason she failed was because of failure

only and my feeling was that from Sue and from

what I looked at at the flow sheet that it was

a combination of increased sputum production

as well as failure and it wasn't water from failure.

She has had increased sputum production

at least 24 hours prior to that when I

was here on Tuesday, acutely.

- [Nurse] When Katie heard that she

got x-rayed last night, she was like...

- Forget it, well anyway to make a long story short,

after evaluating her and having had the word trach

was mentioned yesterday both by Scott as well

as it showed up in Dr. Kerlind's note as well,

Scott said "Why haven't we ever

"asked Bernice what she wants?"

And we all kinda looked at each other

and said "Well, why don't we?"

My feeling in asking her what she wanted was a few things.

Number one, eight o'clock, nine o'clock

in the morning is not her best hour.

I said 11 would be better,

she tends to take a slow day waking up.

The mechanics never are great in the morning,

not that they're ever great but you don't get a good effort.

My other feeling was like okay, so what if she's

able to articulate in whatever form that she can

that she isn't willing to be trached and would

like to be extubated and not re-intubated for instance?

What gives us the feeling that number one,

Dr. Kerlind would also feel like that's

a good idea and want to go along with the situation

as well as her husband and at that point I felt

like it was a great idea to ask her but once

we had asked her and got a good idea from her,

then everything had to be focused through Dr. Kerlind.

I don't think that by any of us that

Dr. Factor needs to be approached by house staff,

nursing, even Scott unless George Kerlind gives Scott the--

- It was only appropriate-- - In that one setting because

we were talking about a very acute demise

and I just said for the sake of all of us

that have to care for her daily, for us to be

the one to go to him with something that he

has encouraged from George Kerlind would not

be beneficial to the situation as a whole.

To make a long story short, Scott went in after rounds,

talked with her, called me into the room.

He wanted me to sort of interpret and watch him talk

and I will tell you, I've never seen Bernice

be quite so definite and it was as clear as day

her answers to all these questions and Scott

went through the gamut by saying that

these are the choices, we're finding that

you're having problems with your heart

in terms of going into some congestive

heart failure and having your lungs fill up.

We also find that because of the fact that

you've had a stroke and your cough isn't good

that you have problems with pneumonia and that

these are problems that you probably will

have throughout the duration of your life.

These are the choices we want to present to you

and we want to know how you really feel about these

choices so that we can better help negotiate your care.

When explained about the trach, the answer was

definitely no with a shake of the head, with--

- The hand. - With the hand.

Saying the word operation, the fact that there would

be an airway in her neck and if we needed to put her

on a ventilator as we needed, that there would be

a way to do that without putting a tube down into her.

Then the other choice was that we would try our best

at this particular point to improve her pneumonia

and then be able to take her off the tube

and make her comfortable so that her breathing

should be easy enough that she would be comfortable

but that if in fact she tired and seemed to need

the tube back, that we wouldn't put it back if she

didn't want it back but we wanted to talk about it now.

- What'd she say to that? - We had to break that up

because that was kind of a long story.

First I started by saying to her,

"All the times that we've put you on the breathing machine,

"have you wanted to be on it?

"Have you wanted to be on it any of the times?"

No.

I did say to her, "Do you realize that

"you've been on it six times already?"

Yes.

Then we went on to say "Do you realize that even

"if we make you comfortable off of the breathing machine,

"that if you need it back and we don't give it

"back to you because you don't want it back,

"that you probably will die?"

Yes.

Is that acceptable to you knowing that

you probably will die if you need it back and we--

- Don't give it to you. - Don't give it back.

- Because you don't want it. - Yes, do you want it?

- No.

So I felt like we broke up the concepts

in four or five different ways so that she could,

we'd be able to decipher--

- [Nurse] You applied it in different situations

and she said no to all, she was consistent.

- She was consistent.

We told her that we would do our best

to make Dr. Kerlind aware of her wishes

and that we would go to bat for her in terms

of Dr. Kerlind as well as with her husband

and then I did say to her, "Do you think

"that your husband will be able to

"support you in your decision?"

And she said "Yes."

And we left it at that.

Dr. Kerlind came in later on,

had a similar discussion with her and she wasn't,

she wasn't able to give quite as snappy of

a yes or no answer to what he was asking her,

which was the same things that

Scott and I had talked to her about.

She wasn't given a lot of time either.

You know Bernice, she's not real quick

with her answers unless there's a definite,

right, you have to be patient to sort of

give her the time so that she can make the effort

and because she wasn't real snappy with her decision,

Dr. Kerlind did say to her that he understood

how she was feeling and that he really thinks

it's an important decision and that she give it

some more thought and that he would be back

later in the day to discuss it with her again.

Later in the afternoon, the plan as it stands

right now is that if we don't see Dr. Kerlind

by around this time, that Karen Ballen would call him

and say that we would really like to take the time

to get together with Dr. Factor while his son is

going to be here through Sunday and also because

we plan to continue the weaning process as her pneumonia

improves but we need to sit down and talk with them now.

If it's something that he doesn't have time

to get into or he doesn't have a chance to speak

to them, being that he's been rounding all day,

that he needs to let us know that and Scott

is gonna be up later in the evening and would

be glad to be involved in actually holding

the meeting or be there when Dr. Kerlind speaks

with them but that we need to all sit down.

So a sort of impromptu family meeting,

whether it's today or tomorrow but we feel like we

need to get the ball in motion and that's where we're at.

- [Doctor] I guess there are just sort of a lot of issues

about what are we gonna do, should we try to take the tube

out tomorrow and see if she flies, if she doesn't fly--

- As long as it is-- - Put it back in, or?

- Well that is something that I agreed

I would re-discuss with her because although

she apparently, Scott got the impression that

she said to him enough, I don't want to be re-intubated

but when I went in and took it up with her this morning,

I was by no means convinced that it was clear in her

mind that that's what she wanted to do and I left it

with her to cogitate it a little bit and then decide.

So I think that that'll be something that we'll

take up with her again.

In any event, I hope that if we get her dry enough in

advance, that we will at least get it out with impunity.

Then the issue of putting it

back in again will be another matter.

- Okay.

Because I guess the son is only gonna be here 'til Sunday,

so it would be nice if we could have him--

- Get her as dry as we can and then

bite the bullet. - Okay.

- [Doctor] We need to talk to you and find out what you'd

like us to do about the tube okay, the breathing tube.

- [Scott] Are you tired of talking about it?

- [Doctor] We want to find out what you want to do, okay?

You're the boss.

- You don't know?

You're not sure what, remember I told you

yesterday what the two choices were.

I think that we can try to take the tube out

and not put it back in the way we did this last time.

But there's a good chance that if we do that,

that you may die

and I think the other possibility

is to do an operation and to put a hole here

and put a permanent tube in here, okay?

Do what's called a tracheostomy

and when Anne-Louise and I, your nurse right over there.

- She knows me. - When we talked yesterday,

I got the impression that what you wanted to do

was to have the tube out and not have it put back in.

But it's important for me to know what you want

because Dr. Kerlind's gonna come back here today

and he's gonna want to know too.

You don't know.

It's hard for you to make up your mind.

It's a tough choice.

It's a pretty tough choice, you're right.

It's not a good choice.

I think that

it's very important for us to do

what you want and I think that knowing,

even knowing those choices, okay,

it's hard for somebody who's

not a doctor to know

what's the right thing to do

and I think a lot of it has to do with how you

feel about what's happened so far in the hospital.

My sense of things is that

if you really want to go on

and you want to live and you want to keep going,

the tube here is the thing to do.

To do the tracheostomy.

I'm sorry, I didn't catch that.

- Are you saying that you still

can't decide between the two, Bernice?

Is that what you're saying, okay.

Do you need more time to think about it?

- All right, that's all right. - That's all right.

You got as much time as you want.

- Is there something that we can answer about

either of the options more clearly for you?

- [Scott] Is there anybody that you would like to

talk to about this that would be helpful to you?

- No?

- What are your worries about it?

Don't wanna die?

Not worried about that.

Worried about your husband?

How he'll take it?

I mean whether he'll get upset

and have a heart attack or something like that?

Well that's a possibility I think.

It's possible that he won't take it very well.

It's hard to know, you know?

I think that that's a real possibility,

that he won't take it very well.

I think that there may be things that we can do to,

you mean either way, either doing the tracheostomy

or doing it, he won't take either one very well or that he

particularly wouldn't take your wanting to call it quits,

which one?

- Is it calling it quits that would upset him,

Bernice, more than having the operation?

- Either one. - Either one.

- It's gonna upset him.

- Either one is gonna upset him, yeah.

Well there's not a lot of good answers here.

Unfortunately.

- [Nurse] Dr. Ballind, you have a call line four.

- But I think that if you want to go ahead

and have this tracheostomy, that's not, you know,

an end of the world kind of a thing.

It's a small operation, it's not a big operation

but it would mean that there would be a permanent tube here.

All that this will do, this operation,

will make it easier to put you on the machine,

make it easier for you to go on the machine

if you have to go on the machine.

That's what it'll do.

It's not gonna change anything with the stroke

or with the breathing because those are problems

we can't really do much about, they're sorta there

and they're gonna either get better on their own

or not get better on their own as the case may be.

You with me?

Are you with me there, did you understand that?

You don't understand that, you do understand that?

- Are you telling us enough?

Yeah, okay.

You just wanna think about it?

- [Scott] Just wanna think about it for awhile.

Okay, we can't wait too long though because

eventually we're gonna have to do something

about this because it's been in for a long time.

- Okay?

- The feeling that I'm getting from you is

that you're not sure whether you want to

have the tube out or have the operation.

I don't know what that means.

You don't want to have the tube out

or you don't wanna have the operation?

No.

You want the tube out?

You want,

do you want the operation?

Yes, you do want the operation.

- Is that what you're saying, Bernice?

- You don't know. - You don't know.

- Okay, so you wanna think about it.

You want some time to think about it.

- Go away. - Go away.

- All right. - Don't feel bad, I get that.

- Let me take a listen to you before we go, okay?

- You've got time to think about it.

- [Anne-Louise] They're gonna listen to your lungs, Bernice.

- Exactly the answer that I got from her yesterday,

that she was uncertain.

I came in after my conversation with you

and thought well, she's made up her mind.

But after I discussed it-- - She hasn't made up her mind.

- No, she has not made up her mind.

- I think she's mostly worried about her husband,

that's what it sounds like when you talk to her.

I think she's got ambivalent feelings herself about the--

- I have to admit, if I were there, I'm not so

sure how certain I would be about what I wanted.

- God only knows, yep.

Okay, well...

Richard's on this weekend.

- [George] Other people go off duty

but your old friend is always around.

So you and I can peacefully discuss this at some length.

My understanding yesterday is that you weren't

quite sure what you wanted to do about this business.

Is that right?

Okay.

You take all the time you need

and I must say that whatever we do,

we can undo it if we have to too.

These are not decisions that are

cast in cement and cannot be changed.

But on a nice day when the sun is shining,

it seems pretty good to be around and Harry's around.

I spoke with him yesterday afternoon.

He wanted to be sure that I understood exactly

what his feelings were and

what he thought yours were too.

You just be confident that your

interests come first with everybody, okay?

- We need to get her sort of

maximally

set up here so that

if she makes a decision,

she either goes for a trach on Monday

at the beginning part of the week

or we extubate her Saturday or Sunday

and see if she flies on her own

and I can understand her ambivalence about it.

It's a difficult decision.

Hard to know.

- [Nurse] There should be a decision beforehand.

- Oh absolutely, absolutely.

- [Nurse] I would not extubate her

until we knew what we were gonna do after.

- Yes, I don't think there's any question about that.

- [Nurse] Especially with her past track record.

It's important.

- Okay, so that's that. - Any other thoughts, George?

- My thought is that as she feels better,

she is not quite sure that she wants to let go.

Today she sorta has a certain spontaneity

and a certain smile to her face which she

had a little bit of yesterday and zero the day before

and so maybe what she really is trying to

say to us now is that I'm not giving up.

- [Scott] What about getting Prikslow here bout a trach?

- [George] I think we ought to have him at least

look at the issue and be prepared to go ahead and I'll--

- [Scott] She'll make her decision on the weekend.

- And I will, Dr. Factor came up to my office yesterday.

Hard to understand what he was trying to say to me.

He just came and he just sorta wanted to hold my hand

for a minute so he was able to get some feeling somebody

really knows what's going on and knows that I'm suffering

and that's literally all I did.

So I think that he, rather than lose her

would certainly go for doing a procedure.

- Okay. - Okay, thanks.

- She's clearly, I mean she's clearly giving us

a different message than she gave yesterday.

She said a totally different thing

to us today than she did before.

- It's hard.

- Well but I, you know I mean as George said,

if that was me in that bed,

I don't know what the hell I'd say.

- He's pulling temper tantrums in the room that aren't

based on anything because he doesn't know anything.

He's teary-eyed, he's getting frustrated.

He started yelling and her arm,

he was hold her hand and she was

pulling him back and getting her upset.

I can't have that happen in the room.

- [Scott] He can't go in there then.

- But he, his son said to him "Dad, control yourself."

And my feeling is I told George Kerlind that

the behavior needs to be addressed and the longer

we keep Dr. Factor in the dark about all these

decisions that are being made, the worse

this is gonna be and I can't take care of him

and take care of her at the same time.

- [Scott] Karen and I can talk to him.

- [Nurse] But why don't you kick him out?

- I did, he left because she was pulling him

back and I said "Bernice, he has to leave."

I don't want to fight with him because

I am her caretaker, that's my concern.

She's already ostracized one

caretaker and that's why I had

to speak to George Kerlind about this.

- [Scott] I think that I'd like to talk to the son anyway

and Karen and I will talk to the son, I haven't met him.

- Okay well sooner than later 'cause the father has

probably gone up to OBGYN to have his coffee up there.

That's where his escape area is.

So anytime, the son is here and in the room with

the mother and I'm sure he would be glad to talk.

- [Scott] Did you talk to him at all

about the discussions we had yesterday?

- I asked Dr. Factor when he went up to

visit Dr. Kerlind yesterday what was said

and he said as George Kerlind did basically

I just needed a friend, I needed to let him

know how upset I am that my son is leaving

and that I'm gonna be alone again

and that the situation is too real.

Those are his words.

No discussions about anything concerning the tube.

When he came into the room just now,

Bernice and I were talking and I asked her

about this morning and whether she'd given it any thought.

No.

I said are you going to give it some thought?

Yes.

I said would you like me to go over

the things that you're giving thought to?

Yes.

I mentioned the options.

He walked in and said to me, "Oh,

"what is it that Bernice wanted to talk to you about?"

I said "Oh, the tube."

And that was it and he didn't get into it anymore.

- Then he went bananas. - Then he held her hand

and then he went bananas.

I think his anxiety is escalating and...

- [Karen] All right, well we can

talk to the son in like 10 minutes.

- [Scott] I'd like to talk to the son anyway

just because I'd be interested to--

- You need to meet him. - Well--

- In terms of-- - I'd be interested, yeah.

I think somebody should meet him and then

I can tell him that, who's the visit next month?

- I don't know.

- Have to find out who the attending is next month but

I can at least tell Schwartstein

who's on for the weekend sort of what,

it's a really difficult situation.

- [Anne-Louise] It's very difficult and he's in

a difficult position because he hates to leave

his father knowing his father is decompensating.

- Right.

- But you have to take care-- - Yeah and I can't--

- Of her and if you have to kick him out, then I mean--

- [Anne-Louise] But just understand that the last time

this all happened is because of kicking him out.

- Right but he has to be-- - What happened?

- He basically went to war with the nurse

taking care of her when the patient was on

her head getting dopamine, not doing well

and Colleen was pulled in two different directions

and he thinks he has dismissed her from the case

and I have told Dr. Kerlind as well as Dr. Factor

that nobody dismisses nursing from the case.

Nursing can dismiss themselves if they don't think

they're in the best interests of the family or the patient

and that's the case but he can't continue

to behave this way and decide how things

are gonna be handled in terms of care, that's all.

- [Scott] That's the problem, he can't go in there

if he's gonna abuse the nurse, it's ridiculous.

- Okay, thank you. - Okay, thanks Anne-Louise.

- Great. (chuckles)

- What happened was basically that was the night

she was doing really bad and she was on pressers

and he would not leave the room.

He was just you know, just being a nuisance

and Colleen just had to kick him out and you know,

we all said he had to leave and then we were like

ready to call security to get him out, you know?

- He was running down the hall like

this with his hands over his ears,

"I'm not gonna listen to you, I'm not gonna listen to you.

"Just go away, leave me alone."

- It was just a very bad situation.

- Well you know what Freud said,

neurosis is no excuse for bad manners.

- You want me to fix this hand?

Do you want me to fix it?

Oh.

Yeah, it's a little swollen

but that will be taken care of.

No need to worry about it.

It's part of the sickness that

you can't move the muscles yet.

That means more healing time, dear.

More healing time.

More healing time.

More healing time.

- I knew her when she came in

the first time with her stroke and aspiration.

I thought at that point that she

and the husband didn't want this sort of long course.

So what happened in the meantime?

- There's been a large debate about this and currently

she and her family are considering whether to get trached

or just to bag it and the husband wants her to get

trached and she hasn't decide yet what she wants to do.

- She's been addressed in the past three days--

- Exactly the most up-to-date.

- She was a pretty convincing no to Scott and Anne-Louise

and-- - Two days ago.

- Two days ago and yesterday Anne-Louise did say she

was more ambivalent after thinking it over for a day.

When she talks to Dr. Kerlind,

it's, he's not as convinced but

you know an hour after Scott and Anne-Louise

talked to her, Dr. Kerlind talked to her

and still wasn't convinced of her wishes.

It was uncertain whether she was as

convincing to him as she was to Scott or whether

his interpretation of it wasn't,

whether he didn't let her answer, you know?

It's been a debate and it's ongoing.

The thing is that the son will be here until tomorrow

and will help Dr. Factor cope with exactly what's going on.

So hopefully we'll have--

- [Doctor] She's been intubated for how long now?

- 14 days.

- [Nurse] Seven times in the last two months.

- [Doctor] What about this most recent?

- 14 days. - Active discussion really

about tracheostomy versus no intubation has

been going on about four days now where

it's really been pushed on on all fronts.

- Are you pushing to do a trach in the next couple of days?

- No, I mean, no I think we can--

- A week or 10 days. - In the next week.

I mean this is sort of silly to keep on--

- She's basically been in

the hospital for the last four months now.

- She actually looks,

in the next 24 or 36 hours I think it would be

optimal to extubate her to give her a fair chance.

I think Wednesday she wasn't given a fair chance.

She was being suctioned every hour,

she was still two kilos too wet.

Now her weight's down to 63,

which is what we were aiming for.

Secretions are down to suction every four hours or so.

To give her a fair chance at extubation

but I don't think long term our options are changing.

- I think when we extubate her,

we have to have a plan about what we're gonna do.

- It's not fair to her. - The other issue for

the long term management of her is that maybe

she needs a trach for bronchopulmonary hygiene--

- I think she does. - And for her aspiration.

- I think it should be done.

- Even if she's not ventilated.

- Right, I agree, right.

- But I think she should have that option

and not Dr. Factor and that's what was stressed

yesterday was that she was our primary concern.

Not that he wasn't but she was our primary concern.

- But she has a lot of ambivalence about--

- I believe, yes. - Yeah.

- But I don't think, I think she has a lot of

ambivalence about being re-intubated, I agree with that.

But I think that tracheostomy should be

explained to her fully and completely.

To say that number one, it's not a cure.

Number two, she's gonna stay just like this

but easier to put her on and off the machine.

Now if she wants that for the remaining of her days,

that's her decision but I think

that has to be explained to her.

It's not like she's gonna get,

her paresis is gonna resolve because--

- Right. - Which,

I mean she's not a stupid woman either

and I think that could be very--

- [Doctor] She's the leader of the family.

- [Doctor] I just think let's address what's important.

- All right, well I'll talk to Dr. Kerlind again.

- [George] The good things are that you're

breathing better and your lungs are clear

and your heart is breathing slowly and regularly

and the bad thing from your point

of view is that tube is still there.

But after we get enough water off

and you've had a couple of really good days,

we'll try pulling it out and see how you do without it.

Okay? Good.

- [Nurse] I told her, so that I'm answering,

hey this is right, Karen wanted to do it.

- Jane talked to her yesterday about

sort of her wishes and her plans for the future

and she expressed a desire to be trached

even if it meant that she would be

institutionalized for the rest of her life,

that it would mean an institutional existence

in a nursing home or a hospital or something.

- Never going home, being in a chronic facility,

living out the rest of her days as she is,

not getting any better and she said that's okay.

We have consensus and I think Doctor--

- You thought she was pretty-- - She was pretty clear.

- Awake yesterday. - Yeah, she was pretty clear.

- But I don't think that this sort of question needs to be

re-addressed then every 24 hours.

If she's at a time when she's--

- But she was originally addressed on Thursday

and she's been thinking about it and her thing

has changed and I think it's good to clarify.

- [Doctor] We have consensus

and the son's gonna leave today, right?

- [Nurse] I assume so, I don't know for a fact.

- Then we can talk with her tomorrow.

- Good because then it becomes obviously

trivial to wean at that point once you have the trach.

- That leads to my next point which is we were

talking about trying to wean and maybe extubate,

try to extubate this weekend but we didn't want to extubate

her until we had a plan about what was gonna happen.

But now I think it's silly and we should just

wait until she gets trached and then try to wean her.

- That sounds good. - So, she can either,

I guess we could still put her on brigs and exercise

or give her some, that sorta thing but in terms of being

really vigorous in trying to get her off the ventilator,

I don't think that's appropriate because

she's gonna have to be on the vent to get her trach.

- How are you this morning?

You look a little worried there, are you?

Are you frightened about something?

About this procedure that they talked

to you about, is that what's worrying you?

Let me explain it to you a little bit.

Two or three times now

when your breathing has suddenly become very difficult,

we've had to put that tube down

your throat to help you breath, right?

Okay.

We're about to take it out again

because you've done well after the last episode

but we're concerned

that if we do and we have to do it again,

it will just irritate your throat

a great deal in going in and out

and so the lung people, the pulmonary consultants

have suggested that we do what's called a tracheostomy

by making an opening here which will give us an access

to your airway so that we can suction it out

so that the breathing can be easy.

This does not have to be anything permanent.

In the past we have closed these over with some people.

Is everything that I've said clear so far?

Okay.

Now, I think the important thing is that nobody

will do anything to you without your permission.

So what you have to tell me is does this

make sense to you to go ahead and do this?

What do you think?

You're not sure, okay, do you want me to decide for you?

Okay.

I think we will because Dr. Schwartstein whom you know

is a lung consultant and Dr. Weiss who is the senior

lung consultant and was on this Board for a whole month

both think it's to your best interests and will provide

more comfort for you and ease in taking care of you

compared to having this tube in your nose and down

into your airway or down your throat into your airway.

These tubes will come out after the procedure.

So there'll be some payoff for you in doing it.

Is everything I've said clear to you?

These are our options at this time.

We'll talk and in the meantime,

we'll try and arrange time in case we all

agree that that's the right procedure for us.

I'll see you later.

- [Scott] He's always on the side of letting 'em live.

- Well if it's not-- - Doing everything possible.

- I think he also is ageist,

it's hard not to be when you're young.

- [Scott] But look, he's a layperson.

- But that's the point.

- You would not,

I mean you're supposed to know your business.

What does he do, he's a lawyer?

- He's a lawyer. - He's a lawyer, right?

If it came to

a tort case or whatever and he said Rachel,

we have to do this, this and this,

you would ask him some questions

about it but he's the professional, not you.

- I know, I would trust him. - Whereas your job

is to interpret all of this stuff.

- See if I came home and I said I have this clinic patient,

she has this hopeless tumor, there's like one in a million.

She's 35 years old, she just had baby

and I can't see putting her through the torture of chemo,

his response would be that's

not your choice, that's her choice.

- Well I think that that's partly right

in the sense of saying that--

- He would probably feel that she should choose the chemo.

- Well but she should have the choice of understanding,

making an informed decision about,

I mean this gets into not the question of DNR

but sort of what is the physician's responsibility?

What is an informed choice and what is, you know?

The problem is that you know,

it's always informed in quotes, you know?

It's yes, we can cure your leukemia but you're gonna

have to spend the next year in the hospital and people

are gonna stick needles in your body every day and

you know, horrible things and you'll be tortured

in ways you never dreamed could possibly occur.

But you will live.

Some people would say well,

that's the definition of Purgatory.

And some people would say no,

I take my chances, I'm going right to heaven.

Do not pass Go, do not collect $200.

I mean you know,

the question is what is informed--

- Well that's the thing.

It just strikes me how as this layperson who's

sort of lived with me through medical school and all,

he still always comes down on the side of

the hope and the chance even though you know,

he's heard quite graphic descriptions

of the chi chi that goes on and so then when I say,

he says it should be her choice and I say yes but you know,

who's giving her the information to make that choice?

It's me and I cannot help,

my bias must come through, I'm human, I'm not a computer.

- Well right, I guess I think as long as you realize that,

I think as much as doctors try to be objective--

- It's impossible. - Nobody is totally objective.

We slant the news and sorta say look,

I think you should do this and this and this.

I am quite nihilistic about what actually happens.

I think that

from a personal point of view, I think you do

real well with the infectious diseases and if you can

exercise, keep your weight down, don't smoke--

- [Doctor] That's easy.

- Then you've done pretty much what you can but you know,

a lot of this stuff that goes on is just not

really relevant to making quality of life

or length of life all that much better.

- To give people quality of life,

you could like be a furniture salesman or something.

(laughs)

It's easy to fix things that are fixable.

- Well it's really rolling the rock up the hill

and having it come back down again.

That's a lot of what this is.

- The instances when it's important to

start raising the question about

withdrawing or withholding or stopping treatment,

I'm gonna use the phrase raise the question a lot

because at no point in this discussion,

because this is all theoretical and hypothetical,

am I advocating in any of the instances I'm going

to talk about that it's absolutely the right thing to do.

There is never an absolute in these situations because

the clinical contingencies as well as people's moral

and religious feelings have as much to do with

these kinds of decisions as any theoretical basis.

So having said that, let me proceed.

There are probably four instances,

kind of general situations that we confront

particularly in critical care settings but throughout

interdisciplinary clinical practice where it's appropriate

to raise the question about stopping treatment.

The first of those is very easy and it has

to do with what we talked about last week.

When the clinical diagnosis of brain death has been made,

any of the support therapies that have been initiated

can and should be stopped.

That seems fairly obvious and probably

is fairly obvious but we've all been in the situation where

we find ourselves or we are working with

physician colleagues who ask families permission

to turn off life-support systems in

the event of a brain death diagnosis.

I think a combination of things result in

those awful situations where patients' families

either can't digest or can't accept or can't

understand the clinical diagnosis of brain death

and therefore have a difficult time going along

with the termination of life-support systems.

For one thing, we as clinicians have to accept

a lot of the blame ourselves, as we said last week,

we tend when we go out to talk to patients' families,

sometimes to soften the blow

with euphemisms that only confuse the issue.

Even saying brain death as opposed to death

sometimes confuses the issue because we imply that

the person isn't really dead and while the diagnosis

of brain death is made differently and there's

a different clinical picture than physiological

death as the distinction has been made,

dead is dead and as hard as that is,

it's more compassionate if we kind of give all

the bad news at once and then rally all of our

resources to support these patients' families

through this horrendous news rather than thinking

that we're buffering them from the ultimate hurt

and really confusing the issue and either giving them false

hope or presenting them with options that are not options.

- How are you holding up? - I'm fine.

- You doing all right? - I try.

Yeah, it's hard but--

- Okay, is there anything I can do for you?

- No, not now.

- Have you been using the medicines at all?

- No. - Okay.

Well if things get to you, you can use them.

Did Al give them to you? - No, he's waiting you know.

But I tried to be calm

and I wanna feel everything right now.

I don't wanna take something and feel

something different, I wanna feel whatever comes.

- Okay, all right.

Okay, anything else? - No.

- Okay, I'll see you tomorrow then okay?

- Thank you, Doctor.

- We're just listening to your lungs.

- Mr. Cabra, how are you doing?

Any pain?

- No, good. - No, good.

He's still got that flush in his mouth.

- [Sue] I'm just gonna test this

and make sure it doesn't look bad.

- [Doctor] I plugged his morphine and his saline line, Sue.

- [Sue] Excuse me?

- [Doctor] I plugged his morphine and his saline line.

- [Sue] Fine, that's fine.

- Since last night, he's had really

a deterioration, we're not sure exactly what's going on.

He continues to have episodes

where his blood pressure drops.

- That's the first time that happened today, right?

- Pardon me. - This happened before?

- It's happened since last night, just today,

since early this morning some time during the night.

He's had episodes where his blood pressure drops

and where sometimes his heart rate drops as well

and the amount of oxygen he's getting

into his bloodstream is less than usual

and you know that it's already not very much.

Are you his wife? - Yes.

- That's what I thought.

It's already not, he doesn't get enough oxygen

into his bloodstream but these new episodes

where his heart rate and his blood pressure change,

we're not sure what's causing those.

It may be an effect of having

prolonged periods without enough oxygen.

It may be something else going on but we're not sure.

It's not surprising that a really prolonged course

like he's had in which he's been critically ill for

a long period of time that he should now become unstable.

But that's not surprising and that's really

what he's doing now and he's never had problems

with his heart before and I think the problems with

his heart really reflect what's going on with his lungs.

- So what's gonna happen now? - Well,

I don't think I can tell you what's going to happen to him.

We're trying to find out exactly what's wrong.

We're gonna get another chest x-ray.

We've gotten EKGs and we're sending off

blood cultures to see if there's an infection.

But so far those have been unrevealing.

- Let me know anything with the results.

- Okay, I know you understand that his overall

prognosis is not very good.

- Yeah, I know. - In fact it's very poor.

- They told me everything and I want

you to be straight, tell me whatever it is.

- Okay. - Okay, I can handle it.

- I think we can expect given what's happened to him

so far and what the course of his disease has been,

I think we can expect him to continue to get worse

and this may be the beginning of a more rapid decline.

We can still look for treatable causes and try

to reverse it but it may not be anything reversible.

There may be very little that we can do in this situation.

As I said, we'll keep trying

and above all we're trying to

keep him as comfortable as possible also.

I know that the doctors that you know a little

bit better have brought up the issue of whether

he should be resuscitated should his heart stop

and that's something that the family needs to

think about again because now he's starting

to show signs of his heart having problems.

If that gets worse, it may come to the fact

that his heart will stop and that there's

very little that we can do except to try,

we can try to restart his heart with very

heroic measures like using electric shocks

and pounding on his chest but in his case,

that's not going to change the overall picture

at all and it's not likely to be too successful but

it's something that we need to bring up with you again.

I know we've brought that up before

and you may want to talk about it and then

talk to us about it again.

It's a very hard thing to bring up.

- I know. - Yeah.

Why don't you talk with the rest of the family and we'll

continue trying to get his blood pressure stabilized now.

- Okay. - Okay?

- Okay, thank you.

- We're doing all that we can for him now, as I said.

We're trying to find the cause

of this and trying to treat it.

It just may be the end of his disease

and it may not be something treatable

and I want you to know that and we're not giving up

on him or anything but I think you need to understand that.

Okay? - Thank you.

- We'll let you know when you can come back in.

- The only think that I really can think of

is that he's got some autonomic dysfunction

just 'cause of nerve irritation.

No other explanation really fits very well.

- [Dr. Brisol] I know.

That's the problem, nothing really fits.

There's definitely a change and I don't know what it is.

His mental status is different also.

- He's much less responsive. - He's not responsive.

- He was less responsive this morning.

- [Dr. Brisol] And they keep backing off, backing off,

backing off on the sedation and he's still not responding.

In fact becoming less responsive.

- I think from a practical point of view basically

our options are to give him fluids

and then use pressers if he needs it.

The last couple days, his weight's not

changed a great deal, he's been sort of even.

He probably has some sense of a loss

in addition to what they're measuring.

So you may be just a touch behind.

- [Dr. Brisol] We just gave him a unit of blood

in addition to fluids and he did this after that.

We can keep pushing on that.

- It took us a few liters to catch up the other day.

- I have a feeling that's not gonna be it.

I saw the family and they have actually

been in the room when this happened,

the wife was in the room and I just

told her that he was deteriorating somewhat,

that he was becoming a little bit unstable

in terms of his heart and that it may,

it might be something we could fix but it

might be just sort of the end-stage of everything

that's gone on and the result of the disease

in his lungs and she understood that.

- I've tried to prepare her for the fact

that he's on the edge and even very small

changes are gonna make a big difference.

I think that deep in her heart she understands that,

though I'm not sure she really wants to believe it.

- Yeah, it seemed like she understood that.

- I know you talked with Dr. Brisol

inside and she called me and I came by

to just have a brief look and talk with her.

He did this same sort of thing about three days ago

but only for a couple of hours and then it went away.

His blood pressure dropped and his pulse dropped

and then it went away very quickly

and we never knew why it happened.

But this has been going on off and on for most of the day.

It's had times when it's been better

and times when it's been worse and we

don't really have a good explanation for it.

We've given him some blood,

we were giving him some intravenous fluids,

none of that so far has made a very big difference.

He may be a little bit better,

his blood pressure is up a little bit right now but

I'm not sure that it's really been any substantial change.

- Do you know for how long?

Because maybe because of the transfusion?

- Well, I don't know if he's gotten

better because of the transfusion or not.

He hasn't gotten substantially better.

I think the point really is that he's not

as well as he was let's say yesterday.

I don't understand why there's been this change.

His oxygen levels in his blood are basically

the same but for some reason or another,

his heart just slows down and it pumps

less hard and his blood pressure goes down

and it's a worrisome type of thing and it's

worrisome in particular when we don't have

an explanation for it, when we don't understand it.

Because then we don't know specifically

what to do to make it better.

From a practical point of view, what we will do is

give him the fluids and give him the blood.

All right.

And if necessary we will give him

some medicine to help stimulate his heart.

Those medicines have their own problems,

they carry their own risks and dangers.

Our concern is that if we can't find an explanation

for this and the medicines and the fluids don't help him,

that we may run out of things to do to help him.

I just want you to understand that he's really very

much on the edge, that he doesn't have a lot of reserve.

But as we've talked about before, we'll do what we can.

You just need to understand that it's obviously a very

critical situation. - Yes, I understand

and I'm aware of everything and I want you

to tell me straight whatever it is.

- So, I've talked with Dr. Brisol and we have

a plan for the evening and we'll just try that.

See how it goes.

All right? - Okay.

- Do you have any questions for me or any other thoughts?

- [Mrs. Cabra] No, just if the medicine,

whatever you're trying to do, it doesn't work, nothing can--

- I don't think there's anything

else we could do to stimulate his heart

and get it pumping harder than those medicines.

They're very powerful, potent medicines.

But I don't think that there would be other tricks

that we would have that we could use to help him out.

So these things really have to work for him.

- [Mrs. Cabra] If the medicine works,

you have to continue to give him the medicine every day, or?

- This medicine would be given intravenously

continuously, it would just go in him

right around the clock, okay?

It's not medicine that we would

give one shot of and see how it did.

- [Mrs. Cabra] How is he now,

his blood pressure really high or?

- It's a tiny bit higher but not very much higher.

It was 77, it's 82 now but that's not

really a big difference and I'm not sure

that's an indication that it's getting better.

In fact I think it really

has to be viewed as just being the same.

We're gonna try more fluids and more blood first

and see how he does, okay?

I assume as we've talked about before

that you'd like us to continue to do what we can to--

- [Mrs. Cabra] Yes, please.

She told me about you know, the shocks.

But I can't make that decision.

it's hard to say.

I can't. - I understand.

- [Mrs. Cabra] So I want everything to help him.

- Okay, we understand and we don't

think that that's an unreasonable position.

We think it's a very difficult decision.

We have a hard time with it too

because he's a young man and

he's otherwise quite healthy

and we'd like him to pull through.

We're just concerned about his chances.

But we will follow your wishes and we will do all that

and we'll try out best, okay?

- [Mrs. Cabra] Because I can't make that decision with him.

- That's fine, okay?

Your decision is not necessarily a bad one.

It's a hard one but it's not a bad one, okay?

- Okay, Doctor. - So we'll just have to see.

And if there are any major changes,

Dr. Brisol will call me back.

- Okay, Doctor. - All right?

- Okay, thank you. - Okay.

- [Nurse] Get ya a chair so that you can sit by the edge.

I can put that down.

- Today you know,

his blood count isn't getting higher,

so they had to put in again more blood.

He hung in there.

But nothing's changed, you know?

I think he's getting worse every day.

Yes, I think so.

Yesterday they told me, had to prepare me about

if they had to use electric shock in case his blood,

his heart start to stop

and they tell me I had to make that decision

if they want to use it or, but I can't, I can't do it.

I can't make that decision, it's too hard.

He's too young, you know?

And I want to give him

any chance to live,

I know he's...

Oh yeah, he's hung in there you know?

He wants us there to believe because I know,

I know he, you know, he doesn't,

he hung in there with all that stuff.

Yes, yeah he's conscious.

Yesterday I talked to him and I tried to encourage him

and I know he was conscious in that time.

But yesterday night,

he was

and this morning when I came, he opened his eyes

and now he's sedated and he's sleeping.

(high pitched electronic beep)

- [Doctor] What's there?

(phone ringing)

- The one thing that she has conceded at this point

is to not shock him if he were to have a cardiac arrest.

Basically what I told her and what she'd like

is for us to do everything up to the point of shocking.

In other words, continue to use pressers

if he becomes hypertensive, to give him

fluid resuscitation if he needs it.

But not to shock him. - Okay.

- If he were to arrest, I think that's reasonable

at this point. - Okay, fine.

- I'll write an order. - He goes for his surgery.

- Yeah and he needs to have a trach,

he needs to have a line, send him for those things.

- [Doctor] If he arrests though, we do CPR, et cetera?

- No, no.

If he were to have a cardiac arrest,

you don't do any CPR or any shock.

But if he becomes hypotensive,

give him fluids and give him pressers.

- [Doctor] All right sounds, yeah that sounds reasonable.

- Okay, I'll write an order.

- Okay, all right thanks. - I'll write an order.

- Thanks a lot. - Yeah.

- [Scott] The other important thing for everybody to

note is why don't you tell 'em about Larry and the family?

- Oh yeah, actually Larry's been on the phone with you.

Maybe you could tell everybody

the situation in which it occurred.

- Yeah.

Just briefly he spoke with the wife at length

and she's comfortable having him

not have cardiac resuscitation done

should he required that.

She said no shocking and no CPR,

although she still would be,

want us to be very aggressive about

antibiotic treatment, pressers, et cetera.

Everything short of CPR.

- [Scott] This is, I mean it becomes

a little bit of an academic issue because

that's not what's gonna happen to this guy.

That's not the way he's gonna expire if that's what happens.

He's gonna pop a flip or just get septic--

Well it could eventually but I think that

it is important for the people to know that.

- [Doctor] The pulses, good pulses.

- [Doctor] He got a chest x-ray this morning.

- I didn't want to,

I said to Larry and Fabricio last, yesterday

in the rounds I said "He ain't gonna make it."

Even before he came back from

the Pickman and he looked worse.

- You haven't been the first one to say that.

I've been saying it for three weeks.

- [Dr. Brisol] I think the problem with

the attending is that it's a chemotherapy complication.

- The guy has quote "a cure" unquote from his embryonal cell

carcinoma so now he's dying of iatrogenic complications.

So everybody feels guilty. - It's a very touchy subject.

- I know, it's too bad people

can't deconflict themselves from that.

They get so invested in the treatment.

I don't know, young guy, you know?

But what a horrible way to die.

Larry's usually pretty reasonable too.

He's not usually difficult to

deal with about this kind of stuff.

He's one of the more, there are some of those

oncologists who really they border on fantasy--

- Psychosis. - All the time, yeah.

- [Doctor] We just dealt with one of them up here.

- [Dr. Brisol] The other night when he dropped his pressure,

two nights ago or whenever it was,

I guess it would be four nights ago,

I called him and he said "Start him on pressers."

Do this, do that.

We didn't reach that point but he clearly wanted it.

- I have a feeling that there's not,

when you can't find any place to put a line in the guy

and he's on gentamycin and then he's gonna get the you know,

the antibiotic for the Andromeda Strain,

you're sorta stuck in the last ditch here.

So I don't think, at least she agreed

to not having us pound on his chest.

Some small victory. - Major accomplishment.

- [Nurse] Dr. Zuma, you have a call on line four.

Dr. Zuma, you have a call on line four.

- The wife, I've never met the wife.

I know

but

did she come in and see him? - Yeah, oh yeah.

- They have kids, how many kids?

Three kids, how old?

- Did you see those heartbreaking letters up on the wall?

- 12. - Nine, five.

- These letters up on the wall,

"Dear daddy, I miss you so much.

"I pray for you to get better every day."

Things like that, heartbreaking.

- [Doctor] They had the priest in yesterday.

- Well you know,

it's hard to know what to do at this point.

I wonder...

Well,

the longer we keep him out,

I mean the longer we're sorta guaranteeing he's never gonna,

if he's got a chance it lies in getting his chest tube out,

lighting up the mussitation, putting him on a T-piece,

seeing if he can breathe on his own, all that kinda stuff.

If we don't do that kinda stuff then

he's just sittin' there waiting to get infected,

waiting to die.

I'm not sure he can tolerate any of that stuff.

I think we may be at the point here where

his lungs are so bad that he's not gonna...

I guess maybe what we oughta do

is just take some small steps.

My own feeling is that if the chest

surgeons feel comfortable taking out his tube,

I would probably take out his tube.

The reason I say that is that eventually

he's gonna get an empyema there, he's gonna get

an infection in sorta the hole open to the outside.

So okay, he's been on the ventilator now for three weeks

and he's not been leaking for over a week.

So let's take it out and then I think we gotta

see if we can pump a few more calories into the guy.

See if we can feed him some more

and

then I guess the final thing would be

once we've sort of got that under control

would be to lighten up on his sedation and see

if we can get him to breathe on his own some.

- It sounds like he is taking breaths.

- That was what happened the past couple days

but again the ventilators, he's up to 30 popping off.

- Listen, when he goes on his own, he's got no lungs there.

He's gonna be--

- That's what he's doing now. - Some amount of restriction

and low lung volume always with him, it's pretty bad.

- I'm sorry, what? - Could you measure that?

I mean could his lungs be so restrictive that it would be

impossible for a human to ventilate those kind of lungs?

- That's possible, in general--

- [Doctor] That was my impression of the situation.

- That may be where we're at.

I think, that's the terminal stage of pulmonary fibrosis

which is basically what bleomycin is is a pulmonary

fibrotic disease and in the terminal stage of any

sort of fibrotic lung disease, CO2 retention

is sort of a pre-morbid phenomenon.

They just, you know they run with a low CO2

because they've had such tremendous respiratory

stimulus from the proprioceptive influences of

the small lung that they breathe, they're

maximally stimulated and then when they just

can't do it anymore, then their CO2 rises

and that may be where he's at, in which case,

we have a sort of significant problem because

if we have to keep him sedated to have him

breathe in the ventilator, then we're never

gonna be able to feed him and it's just

a question of weeks to months before he dies.

I think that overall that's sort of where I see things

being at, on the other hand,

we're talking three kids here, so.

It's hard to,

I guess what, given that he's as sick as he is,

we ought not to make a lot of sudden moves.

We oughta do just one small thing at a time

and not jump in there and really start

flailing away with a lot of major league changes.

I think that you know,

the kinds of things that you could do would be

take the chest tube out, see if you can get

a little more calories into the guy.

Small stuff and then eventually

gradually lighten up on his sedation

and see if we can breathe for him.

If we can still breathe for him with him getting

less sedation, I mean at some point you gotta try that.

- Well that test is what they're trying to do now

and he has a heart rate of 150 and a respiratory

rate of 30 and a peak pressure of 60 to 70.

This is...

- So then-- - When they lighten him up?

- They've decreased the morphine over the past 24 hours.

He hasn't been getting morphine balls, so it's just Valium

and he still has a heart rate of 130

and respiratory rate of 24 to 30.

- [Scott] That's not so bad.

Young guy, his heart's okay. - What do we wanna

go with?

- [Dr. Brisol] He can tolerate a tachycardia

in the setting of trying to lighten him up.

- I guess I would try to do,

I mean maybe the way to do this is to

take out the chest tube and see if we

can feed him and get him a little stronger

and then start doing the stuff with the ventilator

and to not push too hard on that at the moment

and to put that off for a few days.

I guess that's what I'd do.

- [Doctor] Yeah and it might help his semi-pneumonia too.

- To the extent that he does have an infection,

I'm not sure that we want to rip him off the ventilator now.

I would vote for no sudden moves, you know?

Small things, take the chest tube out,

see if we can get some more calories into him.

Don't lighten him up too much.

Ventilate him 'til we get him to the point where

we get the fever totally under control.

Give him a couple more days of antibiotics and then

maybe the beginning of the week we'll try to lighten up,

cut back on the sedation and see

if we can get him to breathe on his own.

- Assuming the best possible scenario just for

my own education, should he come off the vent

and actually do okay and eventually even go home, what's

the best he could hope for in terms of his functioning?

- I can't believe we're looking at

anything more than months here.

- Months of survival and at best,

he would not be able to walk around very much.

- He's never gonna walk around.

- Okay.

- I think the best we can hope for is chronic care.

I'm not even sure we can get to that.

That's the best.

I think that that's maybe one in 10,000.

Maybe even one in a million, I don't know, it's hard to say.

But I mean I just,

based on past experience I think it's pretty hopeless.

So I mean I,

I guess I would vote for sorta just more of the same.

Take the chest tube out, keep him on the medication

and see if we can get some more calories into the guy.

Then we'll try at the beginning part of the week to

see what we can do about the ventilator but I just,

I don't hold out a lot of hope for that.

It'd be worth a try, look I've been wrong before.

You never can tell, you have to try.

(phone ringing)

- Medical Intensive Care.

- [Nurse] No, I got 'em, I'm all set.

Hi, I got a call from Russ Philips on the biopsy.

- She wants to play out the string so,

I think he did too, he's got three little kids.

We're doing everything we can do.

It's just not working.

- I saw Dr. Shuleman this morning,

just to update everyone on the family.

He talked to Mrs. Cabra yesterday and sort of kind of

gave her a very grim picture of how things were going

and just sort of let her know in no uncertain terms

that he was taking a turn for the worse and that--

- [Scott] I think that's important that she know that.

- She still wants everything short of CPR done for him.

She still wants all that done. - Fine, not a problem.

- It's been made very clear to her.

- [Scott] Not a problem.

- Has he been on any steroids?

- Not since he came in.

- [Doctor] Is there any, would there be any benefit--

- Then just wait over there.

Yeah, they told me that too, I checked with the nurse.

Okay good, thanks a lot, bye-bye.

- I just came from talking with the wife

and she doesn't want any of that done.

Take away the antibiotics, keep him on

as much morphine and Valium as he needs

and you know, not deal with his fence sittings.

- No more gases?

- I wouldn't do any more gases or any more blood work.

She's very comfortable with that and I think

we're all comfortable with the fact that

he's just not gonna turn around at this point.

He's been intubated for four and a half weeks

and he's had his ups and downs but it's basically been down.

It's really pretty inconceivable to me

that he's gonna get any better.

And inconceivable to her.

- Has she gone out? - Yeah.

Yeah, she's out in the waiting area.

- That's good.

- All right?

So I'll write a brief note

and I'll talk to whoever's around.

- Okay.

- Okay, do you have any objections

or any problems with that? - Not at all.

- [Doctor] You did a good job helping her, I'll tell you.

Because she's come a long way.

- Yeah, well you guys did a good job too.

I know you spent a lot of time with her.

She appreciates it. - She's so wonderful.

- Yeah, she really is.

She really is and she's comfortable with the decision.

She doesn't feel like she's been pushed at all.

- [Doctor] That's good.

All right.

So maybe I could just borrow this for one second.

- Thank you.

- All right, so that's it.

(chattering)

- DC antibiotics? - Why don't we--

- [Doctor] Yeah, DC antibiotics, no procedures.

- Well obviously, wow.

What, how'd that come about?

- I think that it's just,

I think he's just been kind of gradually

bringing her around to the realization that

he's not getting better and I think it's

one of those things where he's been telling her

that and she hasn't been hearing it and finally

she's started to hear it, yeah, she's started to hear it.

And so,

we're just gonna, you know,

stop the antibiotics and stop lab work.

- Good, no labs. - I think no labs, yeah.

I think no blood gases and no labs.

- No vent setting changes, no--

- Yeah.

- Wow.

- It's appropriate in my mind.

- Oh yeah, it's just tragic. - Yeah, it really is.

Okay Mr. Cabra, I'll start by telling you

his status because that was the most significant

event of yesterday and that is that after

a long talk yesterday between Dr. Shuleman and Mrs. Cabra,

it was decided to actually

withdraw antibiotics from Mr. Cabra

and to not use pressers

to eliminate any blood drawing

and actually just maintain him on a ventilator and

continue to give him his TPN, give him nutrition.

But that was about it.

So that's his new disposition.

Basically comfort measures only,

he's on morphine as required.

- [Scott] I think Leonard made the right decision.

I think that it's been hopeless for a long time and

nothing we could really do here.

It's a tragedy but I mean that's the way it goes.

- If she is competent to make a decision,

then her decision has to be respected,

whatever her private physician or her

husband or what anyone else wants to do.

Those wishes become essentially

irrelevant both legally and ethically.

It's hospital policy, there's no question about it.

Her wishes get respected if there is agreement that

she can understand her situation and make a decision.

There may be disagreement about that, I don't know but--

- There wasn't this morning but I guess

if you ever look back at the past notes

and you read under her neurological status,

that not everybody always agrees that she

has been alert or awake or-- - But the question is--

- To even ask her.

- [Male Doctor] Now when she makes the decision,

she has now made the decision or expressed

a decision and if everybody agrees that

she was with it to make it sufficiently--

- Then there's no dilemma. - Yeah, there's no dilemma.

- [Female Doctor] All right.

- [Anne-Louise] Well then let's think of another one

because we gotta come up with something, right?

- There should be no dilemma. - Right.

- Have people ever sat down in the room

with her and with her husband and with

the attending together and discussed this?

Because that sounds like the problem.

- That's today's issue. - That's the next issue.

- [Anne-Louise] That's what I've been dealing with today.

- But that sounds like that's, no matter what

you're gonna decide if you haven't gotten all

the people together but this is a very different kind of

tone of a discussion than the Ethics Advisory Board

is sort of set up for which isn't supposed to be

complaining about whether one person

or another has handled this right.

- [Male Doctor] This is political rather than ethical.

- [Anne-Louise] I see what you mean.

- Ethical would be you know,

some more question as to whether

or not we really can do this

and

I don't think at this point

in time in our hospital and with our

counsel from the hospital lawyer and all,

there's no question that we can do it.

We not only can do it, we have to do it.

- [Anne-Louise] Right, right, all right.

Well then we gotta think of another one.

- What about the woman with

breast cancer that we were talking about?

- Do you remember her, Kim?

She was the woman that had the tumor growing on the outside

and I used to put that bark liquid stuff,

some herbal, I don't know what it was but anyway.

Yeah and she didn't want to be extubated.

Meanwhile there was nothing-- - Oh yes.

- Do you remember her?

She was in room six. - She was my primary, yeah.

- Young woman, had never gone to a physician

until her tumor was growing outwards.

- And she refused chemo.

- and she refused chemo and then she was on the vent

and was probably ready to start to do something

with the vent and she didn't want anything

different to be supported. - And her family--

- [Male Doctor] She didn't want to be extubated.

- Right, she wanted to stay as she was.

- That to me is,

that's an ethical issue.

That actually with maybe that other woman, do you remember?

- That woman a couple of months ago,

the one who said she wanted to live as long

as she could but the minute she went into

pulmonary edema and needed to be intubated

would scream "Leave me alone, leave me alone."

She had a mental status score of 13 out of like 130

and the family wanted to make her a DNR but every time

we would go in to talk to her...

- That's kinda getting more, this to me is actually,

this is still a sticky point for me as to

there was another woman down in bed 11

back in July who had disseminated endometrial cancer

or something that, it wasn't traditional endometrial

cancer but it was some sarcomatous cancer

that was totally untreatable and everybody

decided that it was untreatable and

she was gonna be sent to a chronic care hospital

from Five South and then arrested unexpectedly

and came up here

and was intubated briefly,

actually got extubated fairly quickly and then

there was a big discussion about what should be done

and her, she said "I don't want to die" basically.

And when people went in and asked her if she

wanted to be resuscitated, she said "I don't wanna die."

But in fact, she had a bowel obstruction and nobody

was proposing to operate on the bowel obstruction

and the issue was what can you do in that situation?

What are you obligated to do?

And it kind of strikes at the same question

as the woman with breast cancer which is

in the situation when we kind of decide

that someone is terminal in a sense, even if they

wish to keep on going, how much further do you go?

And the question is what is terminal?

If someone can live for two months on a ventilator

even with no therapy, no chemotherapy, are they terminal?

The woman with the endometrial cancer,

when I went in and said you're dying basically,

she was aware of that and really

what she wanted was to be kept comfortable.

We essentially told her that there was nothing more that we

could do for her and therefore resuscitation was irrelevant.

How can you resuscitate somebody if there is no therapy?

And this is actually a more kind of naughty

ethical dilemma to me is everybody talks about care of the

terminally ill but there's no blood test for terminality.

What is, what is terminal?

And you read all these things, it's kinda like competence.

Everybody says determine competence

and there's no litmus test for competence.

- All these articles talk about the

medical care decisions for the hopelessly ill

or the terminally ill and they never define what it is.

So you don't know whether--

- What is hopeless or terminal?

Because in a sense if you decide that it's hopeless,

the issue is moot, I mean resuscitation

becomes an irrelevant concept almost.

But at what point?

Given the fact that with a lot of these diseases,

we're talking about a one in 100 chance of surviving anyway,

what is hopeless?

- So what if the title for the session next week is

something along the lines of when is a terminal illness

really terminal or something, some question along

those lines and then we can maybe even have both,

when does a terminal illness really become terminal?

- Andy, I said "How is he?"

And Andy said "Well, he says things like

"she never should've had the chemo,

"she never should've had the portecab.

"If she hadn't had any of that, this wouldn't be happening."

- [Scott] Well,

you know,

is five good months better than--

- [Doctor] I don't know.

- Eight months of hell,

that's what it boils down to a lot of the time.

- [Doctor] What we're planning to do right now

is a sub-max ETT valve in the echo--

- You can't blame him for being,

it's a lot healthier to be angry at the doctors.

- [Doctor] Oh yes.

- I mean who else can you be angry at?

You can't blame it on the kids.

- There isn't anybody tangible

to be angry at other than the doctor.

Better us than her.

- [Scott] I'm sure he's plenty angry at her.

- [Doctor] Well I hope that

this is fast one way or the other.

But I have a feeling it won't be fast.

- God decides.

God decides, we don't decide.

These things have a life of their own.

They really do you know, I mean they really do.

They have a life of their own.

He could go for two,

three days like that easy. - They all ask that question.

If we had done it earlier,

if we had found, caught it earlier.

- Sure, because it's guilt you know?

That's guilt, that's saying it's my fault.

If I had done this, if I had been a good patient.

If I had known what to do,

would it have made any difference?

And the answer is always the same.

Even if it's true that they should've come in earlier,

the answer that you give the patient is always the same.

No, you did everything you could.

The families already feel so bad that

what's the point of making them feel worse?

- I hope the swan goes all right.

I mean that was the scary thing,

when he said "Do you know her history?

"She has complications with everything."

- [Scott] Well it may not go all right.

But you see that's why, I mean--

- I think you spelled it out exactly right.

- Knowing that is helpful though

in terms of the way you view the procedure.

Knowing that, that influences the way you,

you get a little bit less enthusiastic for it.

- Well you can't go cavalierly putting them in but if

anybody needs one, she needs one, that's what I think.

Because I think we are gonna be managing her

for awhile and its numbers might be helpful.

- I guess the question is

are we managing a chance to live

or are we managing her death?

If we're managing her death, I'm not sure we need it.

If we're managing her

with a chance to live, then maybe we need it.

- [Doctor] I'm managing her chance to live.

- Right but I'm not sure he is.

- That may be. (phone ringing)

- I think he's on the fence about that.

- He's trying very hard, well I think he's trying.

He's on one side and I think he's

trying very hard to prepare himself for it.

Andy said he was already talking about

how am I gonna raise the kids, what am I gonna do with them?

What is this gonna mean to me, do I have to quit my job?

He was already, you know,

Andy said 10 pages ahead of the book.

You may be right.

But...

- I don't know but I know one thing,

I'm glad I only do this one month a year.

- [Doctor] I don't know how nurses stay here all the time.

- I don't either, I don't know how they do it.

- I think it's the pregnancy part

that makes it the horrifying thing.

I mean aged it's awful and you know,

healthy its awful and then to do this while you're pregnant.

- [Scott] Certainly the circumstances of it are

far worse than...

Incredible kind of nightmare scenarios that get played out.

(distant sirens blaring)

- Is he gonna make it? - No, I don't think.

- It's white coat day, I see your white coat.

- What's a white coat?

- White sweater, white coat.

- By the way, Mr. Cabra died yesterday at about five p.m.

- Was his wife here? - Yes, very close.

- Was his wife here? - Yes, she was here

and actually it was her,

the feeling of the family was that this was

going much too long and it was really hard for them

and they talked to Dr. Shuleman about turning

his FIO2 down, so we turned it down to 40%

and he flat-lined a little while after that.

- [Scott] It probably wasn't related to that, but...

Who knows?

- There was like 10 family members here.

So,

and she was really--

- [Scott] They don't get any tougher than that one.

- Yeah.

She said you know, if there's anything that

can be learned out of this, then that's

what he would want and that's what I want.

- She was very mature. - She was very cooperative.

So anyways. - Okay.

(metallic clanking)

- Let me do it, you release here.

No I can get it, move your hands, I got it.

Is this low enough, guys?

We cuddly? - Yes.

- You want to go on three? - Yeah.

One, two, three.

- One,

two.

- Three.

Who would like to come down with me?

- [Nurse] Are these the personal effects?

- Do you have a thing for me outside?

Are they outside of the door?

- All right, usually what we do is just put the legs there.

The head or the legs come first.

- Okay.

- Just hold this. - Yep.

- He's heavy.

- Do we need a fourth person? - Yeah.

- [Mortician] Can we have a fourth person to help us?

- You need help? - Yeah.

- Or a fifth. - Yeah.

- Which side you want me to help, this one?

- Yeah. - Yeah.

We wanna go in there.

No, no, no, no.

We want to move him in there. - I know.

- Help her out there.

- We'll be okay.

- [Mortician] One,

two, three.

Thank you very much. - You are welcome.

- What? Sorry. - Just string it on.

Yeah.

- [Mortician] We need to sign that?

- I think just leave it. - Oh, okay.

- We're gonna get everything out of here?

- [Mortician] Yep, we're gonna try.

- He's a 33 year old

white male who presented in December with aortitis

and had a course of antibiotics and subsequent to that

course of antibiotics was found to have a testicular mass.

He underwent a biopsy which showed embryonal cell CA

and he had a retroperitoneale lymph node dissection which

showed five out of seven nodes positive for embryonal CA.

- He had a biopsy? - He had an orchiectomy

with biopsy showing it. - A biopsy.

- Yeah.

Yeah right, he had the orchiectomy and it was documented

then and then he had the retroperitoneale

lymph dissection at the same time.

Five out of seven nodes positive and he received

four courses of chemotherapy including Bleomycin,

was considered to have an excellent response.

However a month later presented with shortness of breath.

Had a lung biopsy which showed pulmonary fibrosis

and his course from there was of

deteriorating lung function.

He presented to another hospital about,

let's see, it must have been,

it was September,

he presented at another hospital with acute

shortness of breath, had a respiratory arrest.

Was found to have tension pneumothorax.

A chest tube was placed, he was transferred

to this hospital to the Intensive Care Unit

where he remained for a month and his course

there was of slow degeneration of pulmonary function.

He remained on a respirator, required very high settings.

Loss of sedation, his peak pressures were often in the 70s.

He had lots of barotrauma besides the one pneumothorax.

He had a pneumoperitoneum.

He had some infectious complications

with very resistant gram-negative organisms and

he required high oxygen FIO2s

in the 50 to 70% range for

most of the time he was in the unit.

His family and his wife specifically

followed his course over all this time and eventually

she made the decision to

not have CPR performed if that was the case

and following that decision,

about a week later she came to the decision to

decrease his FIO2 and he expired shortly after that.

- So the questions for the autopsy were

going back to the original process,

what is the extent of the tumor with that autopsy?

Of course, 10 or 20 years ago he

would've died of metastatic and embryonal carcinoma.

Another question is to document the nature

of the pulmonary process to determine if

in fact it was an irreversible process

likely related to the Bleomycin treatment

and the subsequent treatment and finally

to look for unexpected processes that might've

helped to explain some of his clinical course.

Go ahead.

- So the autopsy is a large gentleman

and on careful dissection of the retroperitoneum,

we revealed multiple adhesions but

no gross evidence of tumor in the lymph nodes.

He also had a history apparently of a congenital absence of

a left testis or atrophy and there was no evidence of that.

He had had a right orchiectomy,

so the right testis was also gone.

- [Male Doctor] Basically there was no

evidence in the gross of any residual tumor.

- [Female Doctor] No microscopic evidence.

The most remarkable evidence

was found in the thoracic cavity.

He had 100 CCs of

serosanguinous plural effusions

bilaterally and both of his lungs weighed about 800 grams.

- [Bill] You really should feel these, put on gloves.

- Three times normal. - Important to feel it.

- [Doctor] Virtually no homeostasis in here.

- [Bill] Yeah, looking at them it isn't

evident how fibrotic they are but to touch,

it's a very woody consistency.

- [Female Doctor] I think too there was extensive

fibrosis and there seemed to be a superimposed--

- [Scott] There's a band of fibrosis right there.

- [Female Doctor] Abscesses, small focus abscesses

and post-mortem cultures were positive

for gram-negatives and staph epidermis.

- Some seminiferous change. - Bronchiectasis.

- Plural on the other side. - A little.

I think that fits in with the fibrosis.

Of course at this stage, any of a number

of things can present a picture like this but

it is completely consistent with Bleomycin-

induced fibrosis perhaps with a component of ARDS as well.

Diffused cellular damage.

I think when the clinicians come, we'll take

the opportunity to mention how posts were

important in characterizing this form of toxicity.

So there really were no surprises at autopsy.

- This is an example of curing the tumor but that the cure

was deadly.

The therapeutic index is very low.

- Unfortunately we only see these patients at this point

but I think it's significant to mention that only

a real small percentage of the patients have toxicity

to Bleomycin and this kind of a cancer has an 80

to 90% cure rate and unfortunately there's 1%

or a small percentage of patients that get drug toxicity.

- Okay, why don't we do the next?

(sirens blaring)

(electronic beeping)

- He's going under right now. - Full anesthesia?

- One set. - Just one set.

- Is that his vital signs? - Mr. Sporiza?

- Finish his blood pressure. - Has anesthesia been called?

Call 'em, he needs to be intubated.

- [Nurse] Does anybody have a

tourniquet on them?

- The other way around. - Do you have a tourniquet?

- Check the second drawer.

- [Nurse] Gonna try and get a line in.

Do you need any drugs, Suzanne?

- Yeah, can you get me the intubation,

get me all the drugs from the kit.

I don't have anything in here.

- He's on the wrong one.

- He's just like not breathing.

- He just suddenly stop breathing.

- Were you in the room or what?

- [Suzanne] Yeah, he went into a weird rhythm

so I went to get an EKG and just started

dropping his pressure and turning blue.

Neo, single strength tube.

(chattering, overlapping voices)

- [Technician] Get the MG tube with the suction, please.

- [Nurse] Over on that side,

can somebody turn on the MG tube?

The suction over there.

Okay, I'll get over there. - It's around the back.

Can I have a needle for this? - Okay.

- [Nurse] Saline's going in.

Gloves, here's gloves, big and small.

Got it? - Nope.

- No? - Blood pressure's at 70.

- Can we put him under? - Yeah.

- [Nurse] You know what, brush him off.

- [Nurse] Can someone mix up his dopamine please?

Dopamine.

- [Nurse] I'm just gonna try this one.

(electronic beeping)

- You get it? - Yeah, we'll go again.

- I'm moving the head down. - Okay.

- Take care of him.

- [Nurse] Just trying to put a line in here.

Don't, no, just wait a minute.

- [Nurse] He had a tube right here.

- [Nurse] Can you just

unplug that amidone to top it out, Josh?

It's about seven.

- [Doctor] Rachel's taking care of him

and I'm gonna go finish rounds.

- [Nurse] Well that's gonna look good in about five minutes.

Do we have a triple bowman thing?

- Yeah, right here. - Oh good.

Just open it up, place it on there.

Looks good.

Gas?

- Do you want a quarter, what do you want?

- Do we still want this fluid running wide open?

- Neo, please. - What, Karen?

- Neo. - Neo.

- Did we get any back the other day at all?

- [Nurse] Nothing.

That suction draws up his tube to the back.

- [Nurse] Use this to push through here,

where is the dopamine?

- It's the central line. - Dopamine flowing.

- Yep, wide open, 500 an hour.

Saline is wide open. - We have some more saline?

- Blood pressure is 60. - We have an atropine ready?

- [Nurse] Atropine is coming.

- Put that on wide open neo. - Wide open neo.

- [Nurse] Wide open neo,

wide open dope and wide open fluids.

Is that correct? - That's correct.

- Obliterate 50. - Pulse is definitely better.

- Just gonna turn it on. - Who's got the neo?

- [Nurse] Dopamine.

No.

The two port is saline.

- [Nurse] All right good, we need saline.

(overlapping voices)

- [Nurse] I can do it, I can do it.

- I'm the one who'll do it.

Please? - Okay doctor, go to it.

- Bags 302, seven. - 100 more grams of lido.

- Okay. - 100 of lido going in.

- There's one. - I got it.

- [Nurse] So you wanna put him in sync mode at 50.

- [Suzanne] You wanna zap him out of this?

[Nurse] All right, here we go.

- Is it charged at all? - You can charge there.

- Consistent blood pressure. - Clear.

- Clear. - Clear.

- [Nurse] Jeff, you're still touching the metal bed.

- Yeah, charged. - Right leg back.

- [Jeff] Clear.

- [Nurse] You gotta hold it 'cause it's sinking.

- Okay. - Flow right away.

Now you've got-- - Something...

- Now we've got-- - We've got the--

- Kind of ventricular-- - Ventricular.

- No, it's awful slow. - I know.

- We have a good blood pressure.

- [Nurse] He's got a better blood pressure with it,

he is to 70, hold on.

Don't shock.

- [Nurse] Looks like a flutter almost up here.

There you go, that's better.

- [Jeff] You've got a blood pressure of 80.

- It's a narrow complex now. - Yeah and it's a long, yeah.

- [Jeff] Narrow complex with inverted teeth.

- [Nurse] It looks like he's switching

bundles or something, can you tell up there?

- [Nurse] Some bundle and a little pacer.

- The P-waves aren't much. - Blood pressure's better.

- [Jeff] That looks like P-waves with a bundle.

- Just turn the amplitude up a little bit, Sue.

So that it picks up the heart rate.

Thanks. (electronic beeping)

- [Nurse] Did it flutter, three?

- I think it might be sinus. - Sinus.

- [Nurse] See those spikes you're seeing?

That's the offender.

- [Nurse] 62.

(overlapping voices)

That neo and dopamine's still wide open.

- Why don't you start that? - He's 70 systolic right now.

- That's better. - You know why he's

probably hypotensive now or

one of the reasons he may be-- - His bladder.

- No, I think that one of the major reasons

is that we may have blown off his CO2 too much

and I think it would be a good idea before

we start pouring a lot of drugs into the guy

to get another gas and see where you are because

his baseline PCO2 is like 60,

70 and I'd slow down actually a little bit, Frank.

Because oxygenation was the main,

and I think that just his pH could be 755, 76

and that could be all that's going on here.

So-- - Okay.

- I just, I can take responsibility for this one guys.

When I saw him this morning, I should've

told you to go ahead and intubate him right then.

That's the, no he was not breathing this morning very well.

- [Doctor] He wasn't moving a lot of air.

- I think the problem is that he was so down

mentally because he's been that way, you know?

But I think that, I would not make a big thing

about not putting a central line in him like last night.

I mean a central line is not the answer to the guy's

problems but if anybody made a mistake, I made

the mistake this morning in not suggesting

that we go ahead and intubate him electively.

So I think that's where the error was.

- [Doctor] I think something happened between the time--

- I don't know, I don't think, I'm not sure.

- He's just quit breathing. - He's just out.

- [Scott] He just pooped out, I mean he was pooping,

he was pooping over 24 hours. - Within 15 minutes.

- He was pooping out over 24 hours, know what I mean?

He didn't look good yesterday in the evening

and he sorta gradually didn't look good

all night, so I think that's basically

what happened and I think it's just

a question of a guy being dry,

infected and

not waking up from the ad van

and not having a great respiratory drive.

- Charlie, can you hear me?

Charlie?

He's not very responsive.

Thank you, you guys.

Thanks everyone.

- You wanna keep this on? - No, go.

- I think that now pretty clearly he's

gonna go down to a valvuloplasty on a ventilator

and maybe it'll make him better and maybe

it won't but we don't even know after all

is said and done what sort of a brain

we've got here after all of this stuff.

We're gonna have to reevaluate the whole

situation after we sorta get him stabilized.

The thing that's tough is you get a case like that

and you've got a one in 100 chance of pulling

the guy through and you work like hell and you

stay up all night and you're almost there,

you think like he's gonna make it

and then he goes down the tubes again.

But like I say, you do your best and that's

all you can do and I think that aside from,

I mean everything would've been fine if Scott

Weiss had said look, we gotta call anesthesia

and get them over here and intubate him electively.

I think that was a mistake on my part.

I don't think that anything that you

guys did last night did or didn't matter.

If you look at the course of events,

he was sorta dribbling a little bit as we went along.

Let's finish up and see the rest of these people real quick.

There's enough stuff to do here to

keep everybody going for awhile.

- [Doctor] Okay.

- I mean the tendency

here is for all of us,

I mean certainly for Woody and for me,

the tendency is in general to say stop.

- [Nurse] We have a warped sense of looking at things.

- That's right.

That's right, I mean that's exactly it.

That's right and that's why I think

that because that's the tendency,

it's very important to give 'em the benefit of the doubt.

So Mr. Cabra got an extra 10 days on

the ventilator before he died. - I agree with you.

I am a big believer that everybody deserves a chance.

I don't care what you have, go great guns.

But then when you're working on the month,

the two month, the three month,

there comes a time when you gotta realize

we've offered everything we can.

- I think the other thing is I have never had a problem

ever in dealing with a family about any of this stuff.

No, no, no, I've had plenty of problems with families.

As long as I was able to establish

a relationship, we'd get there.

The problem is you get into the situation where--

- You guys switch around. - Certain, you know,

stuff has been done before they come here.

- [Nurse] They come with a lot of

baggage already, I know what you're saying.

- There have been a few situations, really crazy

families where no matter what you did, you could never--

- [Nurse] Gypsies and stuff like that.

- I don't know about gypsies but I think in general

if you have a good relationship with them and you

sort of are honest with them about what's going on

and say look you know, your father or whatever is dying--

- But that's why I think we have

more problems with asking people here.

It's house staff, it's changing

and we want to keep getting to know the family.

How do you feel, what do you think?

Have you ever talked about this?

Where in community hospitals, other hospitals,

there's an attending and there's a family whose probably

taken care of 'em for years or knows the situation--

- Where my sister practices-- - Right.

- She's taking care of these people,

yeah and she doesn't, she doesn't,

I can tell you, if somebody comes into a hospital there,

she doesn't say

"What do you think?"

She say-- - This is it.

- Your father's dying. - Right.

- If you don't know somebody and you've

never seen 'em before, it's very cavalier to say--

- [Nurse] To say oh, well I know more than you do.

- Check out, I'm sorry but-- - It's all over.

- You end up, and clearly I mean,

clearly the house staff's sense of,

if you haven't seen 10,000 patients,

even if you have seen 10,000 patients,

I'm not ever sure, you know what I mean?

I'll tell you, Mrs. Pergolin, there is a good example.

I'd never seen that lady before, she shows up here.

All the stuff that went through my mind was

you know, has she,

have they really established a diagnosis?

What else could she possibly have?

And I started asking myself all these questions.

You still get uncomfortable about,

I mean I'd never seen her before

and yes, they say she refused chemotherapy in New York.

But did she really and what were

the circumstances and what was she told?

So I mean you know,

if you're cavalier about somebody like that,

then you oughta get outta the business.

- [Nurse] Did your best friend get diagnosed with

similar things and die two weeks after chemo, you know?

- [Nurse] Part of the job is unfortunately

like you said to take responsibility for it.

To also ignore that.

I think a lot of people because they have difficulty with it

almost like, especially certain, like an attending physician

almost puts it onto say the attending of the unit

or they have the relationship with the patient because--

- [Nurse] In her case that wasn't true.

I think you're right, what you're saying is that--

- [Nurse] Because it's a hard thing to deal with.

- In a situation like her,

they would take all of those uncertainties and it

would make them very nervous and then they would

just abdicate and say "You gotta make a decision."

But I think you gotta be very, very sure.

There are few situations though in life where

the critical meaning of what you say and how you say it

has as much ramifications as it does around this issue.

- How you doing?

More bad news. - What?

- I said there's more bad news,

one thing after another with what's been going on.

Right now there's no change since I spoke with you but

this latest set of episodes has--

- It's not different?

- Not from when we spoke on the telephone but

he hasn't shown any recovery from that.

They're giving him some other medication now

to try to help his heart pump a little more

effectively and to see if that could be helpful.

- There's been a whole series of one problem after another.

- Why, he's been coming here so long.

He never had these problems.

What happened?

- I'm not sure we have the complete answer to that.

But you know the attempt to see how we'd do

in getting him off the breathing machine,

it looked like things were getting better and better

and he was remaining stable. - He was good.

- But he was in such a precarious situation that

we've seen some of the things that can happen from that.

I don't have an answer for you as

to why it was that it happened now.

It's possible that there may have been some

additional injury that happened either to his

heart or elsewhere that we haven't detected yet

and that may be the thing that caused all this.

- Is he holding his own now?

- Well, I guess it's fair to say barely.

I think in the last hour or two,

his blood pressure has been a little better

and his heart rhythm had gotten a little bit stronger.

His heart rhythm had been irregular

and it's now more stable but

I think the big picture still looks very grave.

Excuse me.

- Are you telling me that he doesn't have too much hope?

- Well I think there's always hope.

We don't know for sure how to predict the future but

I think these things all make us concerned about

and make us wonder, we don't know.

But each one of these things that happens is more

bad news and more for him to contend with if

he's gonna have any sort of meaningful recovery.

- Didn't he respond at all? - No.

But we don't know if that's because there's an

underlying problem that's causing him not to respond or

whether it's still a lingering effect from the sedatives.

Even off of it for a couple of days,

his kidneys have been not doing well

and his liver has been not doing well

and those are the things which

get rid of the sedative from his body.

So then it's possible that some of the effect

of him not waking up was from the medication.

But I think we also have to consider the possibility

that even once the medication's gone that we may find an

underlying problem that's responsible for him not waking up.

- He was always complaining about his kidneys.

I just feel so terrible.

He was so unhappy.

He was so sure he was gonna die

and I think that that's uppermost in his mind.

- That he was sure he was gonna die?

- Yes, that's all he said.

Of course I said "Gee darling,

"you've been doing pretty good."

He managed around the house but

the last week before we came in here,

he couldn't even go from the bedroom to the bathroom.

Well,

I'll put it in the hands of God.

There's nothing I can say or do except pray.

Can we go in the room?

- [Bill] Let me check with the nurse

to make sure that it's okay.

I'll be right back. - Okay.

- [Dr. Brisol] The technique is poor.

- She really feeling it? - Yeah, she is.

- [Suzanne] That's probably the smart thing to do.

- Has he talked to you at all?

- A little bit.

A little bit, not much but I had to give him some

medicine to put him to sleep again to keep him comfortable.

- Can we sit here quietly?

Okay.

- We have chairs here, we have chairs.

You can talk to him if you want.

You never know, he might hear you.

Way down here.

- Charlie.

Charlie.

Why have you got the tape on his eyes?

- Because his eyes were wide open,

he wasn't keeping 'em closed by himself.

So I didn't want them to get dried out.

It's more comfortable this way.

Hi Charlie, Charlie, do you hear me honey?

Do you hear me?

- [Suzanne] Do you understand what happened today?

- [Mrs. Sperazza] No.

- Well he was doing about the same as usual

and then he just got pooped out from breathing.

He just suddenly tired out completely and stopped breathing.

- He stopped breathing? - He stopped breathing,

completely.

So we had to put him back on the ventilator

but his heart at the same time had

started to go into a funny rhythm

and he dropped his blood pressure too.

He's on a lot of medications

for his blood pressure right now.

- I don't understand, he wasn't this sick at home.

Do you suppose it was coming on?

- It was coming on.

It might just be his time, you know?

He has a sick heart, he has a pretty sick heart.

- Yeah? - Yeah.

- He never got treated for that or had any problems or--

- Well he was on Keptakrel, that was for his heart.

- Oh was it? - Yeah.

He was on a couple heart medications at home

and that's why his lungs kept getting bad this year.

It's because his heart wasn't pumping right,

so the fluid was backing up into his lungs.

Yeah.

- [Mrs. Sperazza] How can you tell

if he's doing better or not?

- [Suzanne] We watch his blood pressure and his heart rate.

- That lets you know, that's good.

- [Suzanne] Just his numbers,

that's all we can go by right now.

He has gotten better over the last hour.

- Really?

- He's gotten a little bit better.

His blood pressure's gotten better,

his heart rate's come down.

We've taken him off some of the medication,

so he's getting better.

But he had a pretty touch-and-go-morning.

- I called last night about 8:30

and Allison said to me,

"He's had a little trouble breathing."

So he must've started getting bad last night.

- He started getting bad last night.

His breathing was okay but his heart

went into a real fast rhythm. - Oh.

And they had to zap him, cardiovert him around

five in the morning to get him out of the rhythm.

- Oh.

- He was stable for about four hours and then his

heart just kinda slowed down and he stopped breathing.

So we had to put him back on

the machine and we had to zap him again.

- I don't believe it, he was a tiger.

If you knew how I used to beg him about those cigarettes.

Can't blame it on any one thing.

We're gonna stay around if you don't mind.

We won't,

you know-- - Come on over here.

Did Dr. Taylor talk to you?

Well at this point if his heart were to go

into a bad rhythm or if it was to stop again,

we can give him drugs and we can shock him,

we can try to save him or if you think that he's gone

through enough, you can decided for us to not do that.

To just keep everything we're doing

right now but not start anything else.

If you think you've been through enough with him--

- [Mrs. Sperazza] Oh no, I'd want him to have every chance.

- [Suzanne] You want him to have every chance, okay, okay.

We have to ask you that and that's very reasonable for you.

Okay so we can pass along, I'll tell Dr. Taylor that

or if he doesn't ask you, I'll pass that along.

- Okay, thank you.

- [Suzanne] That we'll do everything for him, okay?

- Everything, every conceivable thing.

- [Suzanne] Okay, okay.

- You've been so good, Suzanne.

- [Suzanne] I know this is difficult for you.

- I don't know what else they can do.

He's my life, he's my life.

I was so afraid I'd go and leave him alone.

- [Nurse] Really?

- [Doctor] So you can come in any time.

All right?

Okay, bye-bye.

- I didn't even drive in today because I was afraid.

We had to wait three quarters of an hour for a cab.

I don't think I should be driving when I feel like this.

- [Bill] Yeah, I think it's smart.

When's your next appointment to come in and see me?

- 23rd.

Charlie had an appointment with you too.

- [Bill] Yeah I remember, we set that up.

- Yeah.

- [Bill] I'll see you sooner

if you think that would be useful.

- While Charlie's still here, I'm not thinking of anything.

- [Bill] What's your sense with

what's going on with him now? - My son?

- [Dr Taylor] What's your sense

of what's going on with him now?

- I think he's in bad condition.

- [Bill] Do you feel like you have an understanding

of what's happening to him as much as you want to have?

- Not really, I can't understand why he's so sick.

I mean you're mentioning liver and kidneys.

How did they all enter the picture?

- [Bill] Well what happens from whatever

the original cause is, when the heart is not pumping

efficiently and the blood pressure goes down,

the circulation to every organ is affected.

Part of what the heart does is supply

every organ with oxygen.

When the lungs aren't working well,

not as much oxygen gets in and then when the heart

is not pumping well, every organ can be affected

by the poor circulation and I'm afraid that's what

he's been through is that the heart problems and the

lung problems have probably set everything else off.

His kidneys are not working well at all.

His liver is not working well.

His blood sugar is out of control.

As we discussed on the phone, we have questions

about whether he might've had any brain damage

from what had gone on in the few days before

and we were hoping that once we could stop

the sedatives when he was off the machine

that we could see if he would wake up

at all as a sign that his brain was doing okay.

So we have, everywhere we turn--

- There's an obstacle.

You know he said all week before he came in,

he screamed, he said "I'm going crazy.

"I'm going crazy."

It's just like you know, the girl that

used to take care of him that went to California,

he said "I feel worse than when she was here."

- When Dr. Gartol left? - Yeah.

- Yeah, that was a big loss for him.

- It was a big loss for him.

He didn't particularly take to

the doctor that took her place.

- Well I think any time there's a close

relationship as he had with that psychiatrist,

finding a replacement is very difficult.

- I know.

What can I do, Dr. Taylor?

- Well I think to be here the way

you are is probably the most important thing.

We don't think that he's able to sense much

in terms of what's going on around him.

But we never know and I think your presence,

your visits are probably the most important thing.

- My son came in last night, much against his will.

He just can't bear,

and he's so good but sickness just does something to him,

to just see somebody under these conditions.

- [Bill] Would it be useful for him to talk with me?

- I don't think so because

I'd say almost he was a Christian

Scientist if I didn't know better.

He won't go to a doc himself, he has the Harvard plan.

If he hurts himself someway,

he'll go to a doctor but other than that,

he heals himself.

- You might mention to him if you would that I'm

available if he thinks it might be useful for us to talk.

Even if it doesn't mean coming in,

we can even speak on the phone.

- I will if you don't mind because

I kinda talk to him about breaking down

and then he gets upset when I break down

and I don't want to do it, I don't do it intentionally.

- Well it's not necessarily a bad

thing for him to know how you're feeling.

One of the big questions from a medical point

of view is whether we should go ahead with this

procedure that we've talked about doing

where they put the balloon in and try to

open up the blockage in the heart valve.

It's a very, very difficult issue because

on the one hand with all the difficulty that he's having,

we don't want to subject him to the further difficulty that

could come if there were a complication from the procedure.

Because on the one hand, if it would offer him something

and the chance of a more meaningful opportunity to recover,

we certainly don't want to withhold that from him.

- No. - On the other hand,

if it means putting him through one more procedure

for no purpose, if it's not gonna help him

have a more meaningful chance of recovery,

we hate to subject him to it.

Not only from what the procedure does

but in case there could be any

complications from it or any problems because

although it's a relatively safe procedure,

there are complications-- - You explained it to me.

- And in his condition,

the possibility of complications always goes up.

When there are so many things--

- [Mrs. Sperazza] What does that leave you with, nothing?

- Well I don't know, I think it leaves watching,

trying to do the best we can to stabilize him

and then to keep making this judgment as

best we can with the best input we can get.

Dr. Morgan has known him for awhile.

- Oh yes.

- [Bill] He's very thoughtful and careful

about giving advice about these things

and I think his opinion is gonna be

a real important one in terms of

whether he thinks this might be helpful.

Because you know back when he was evaluated,

when Charlie was evaluated in July,

it didn't look like the heart valve

was causing the primary problem.

- I know, that's why I don't understand this.

- [Bill] Well one of the things

that that says to me is that we have to be

careful, we don't want to rush ahead

and subject him to something unless we're

pretty sure that he's likely to stand to gain from it.

In the meantime, every additional problem

that develops is another strike against him

in terms of what we're all hoping for.

The possibility of some meaningful recovery from this.

- Is it possible that medication will help him?

- Well he's on medication. - Yes, I know.

- We're trying different ones to see

if we can find the best combination for him.

So we're doing what can be done with that

and not giving up in terms of trying to be helpful.

But I think to try to be realistic at the same time,

the more this goes on, the more complications that develop

in spite of doing everything that's being done,

the worse it looks.

- He's not suffering, is he? - No.

To the best of our knowledge, he's not.

When he's been resisting the tube or

looking like he's at all uncomfortable,

he has gotten the sedative medication to

try to take the edge off of that and try to make sure,

I believe since this tube has had to go back in

that he hasn't required much in the way of the sedative

either because there's still some in his bloodstream

or because he's so sick that he's not able to--

- To fight. - To fight it or to

experience it.

- So what do you think, wait and see?

- [Bill] That's all we can do.

I think in the meantime we have to keep assessing

what's our goal for all this?

- Yeah, that's what I want to know.

- If there is some hope for some meaningful recovery,

we want to do everything to help him to achieve that.

If it reaches the point where that

isn't really possible, then we're gonna

have to reassess and say is it the right

thing to do to subject him to all this,

to all the tubes and the machines and the medications

and everything that goes on here in Intensive Care

if it's not gonna be for some purpose

in terms of him being able to recover from this?

And at this point I think we don't know,

we never know for sure but the longer it goes

with more and more complications, the less he

responds to all the different things that are being done.

- Couldn't it be just the opposite,

that he will start responding?

- [Bill] That's the hope.

- Oh, Dr. Taylor.

Well,

I'm gonna go along with the hope

that something will be resolved.

- [Bill] Let's stay in close touch.

You know how to reach me anytime.

- Oh yeah, I called you yesterday

and Paige had you on the line so long and then I

just hung up and I tried Dr. Morgan and I got him.

- [Bill] Good, sometimes when they

page me, the beeper doesn't go off.

- Oh yeah?

- Call and page again when that happens.

- Oh. - Okay?

- I thought maybe you weren't on page, you know?

- [Bill] No, they'll know that if they tell you

that I'm not on page, ask them for a number where you

can leave a message for me and then I can call you back.

There's always, if I can't be paged,

there's always a place where you can leave a message.

- Oh, I didn't know that, thank you.

- [Bill] Tomorrow I'll be

here all day and on page all day.

So you can speak to me later today through

the page operator or tomorrow, I'll be here.

- [Mrs. Sperazza] Dr. Morgan was very nice, he spoke to me.

I don't know what that doctor's name was.

He told me the most horrifying things

that can happen with that procedure.

- Yeah. - But of course I,

I imagine that they have to do that, you know?

- That they have to do which?

- [Mrs. Sperazza] Tell you all

the bad things that can happen.

- Yeah, I'm afraid they do.

Because the last thing that you'd want to have happen

is to have him go through it and have something

happen that you never even realized could occur.

So they want you to sort of have your eyes open.

- They've only done 140 of these.

- [Bill] It's a brand new procedure.

Most hospitals, my understanding is

most hospitals don't have it available.

We're fortunate to have people here who

are skilled in it but it's brand new, so

doing it has its hazards even though they

appear to be small and we also don't

really know about the long term effect.

- That's what he said and you also

don't know if that's what he really needs.

- That's the key, that's what we're trying to sort out.

My own view is that we need to hold off on that

right now and see if we can start to show some

signs of turning the corner, being stabilized,

looking like there's some chance of meaningful recovery.

Because I would hate to subject him to it

and have it be for no purpose or even worse,

to have it be something that causes him additional problems.

So if it looks like he's able to hold his own,

he is able to start to show some signs of recovery,

I think we'd have to assess whether it might be worth doing

and as I say, I'll depend very heavily on Dr. Morgan

and the rest of the cardiologists about whether--

- [Mrs. Sperazza] Will Dr. McKay be in on this?

- Yeah, well Dr. McKay is the one with

Dr. Safien who are the experts on doing it.

- [Mrs. Sperazza] Oh, I see.

- Dr. Morgan's consulting with him all the time

about whether it's something that would be useful for him

or whether it should be done soon or we should hold off.

Just what would be the best sort of plan.

- I don't know what I'd do without her.

I mean,

she walks my dog in the morning.

Poor dog doesn't know where Charlie is.

He keeps going and looking at the bed and he's so sad.

He leaves a hole everywhere.

You know Charlie from here,

Charlie is one of the,

I mean greatest, that's all I can say.

The kids adore him when they see him coming down the street.

If your Daniel saw him, he'd fly in his arms.

That's the way he is. - I know that about him.

- Yeah, he loves children.

And the kids have all asked me,

yesterday they gave me drawings to put in his room.

They were horrible, I didn't dare

tell the little girl what I thought it was.

I thought it was a candle.

She said it was a Christmas tree.

- She's working on it. - She's working on it, yeah.

- [Bill] Maybe the spirit of what's behind that--

- That's right.

- [Bill] Well I'll be around later today as I say

and tomorrow as well, so let's stay in close touch.

- Oh yes, I may go home for a little while,

straighten the dog out, lock up the house.

But I'll be back, I'll get a ride back, I won't drive.

- [Bill] Good, that's the right thing to do.

- Thank you so much for your time and your kindness.

- Thank you, Dr. Taylor.

- So,

I just you know tried to explain to the wife

in pretty simple terms the scenario of things.

She's aware that he is doing very poorly.

But she still very strongly feels

that she wants everything done for him.

- [Nurse] Did someone bring it up and she definitely said--

- I said to her if his heart stops

or if he goes into a bad rhythm I said we can shock

him and we can give him drugs, is this what you want?

And she said "Oh God yes, I want everything done."

- [Nurse] Okay.

- But the sister I think has a little bit more realistic

view of the situation and she's not as emotionally involved.

- She might just need time to accept this.

- And that's what the sister said and I said to her,

I said I would not be surprised if something sudden

happened and I said I really don't want to mention

this to her but just don't leave her alone at home.

I said you know, just be prepared that something

could happen and that he's doing very poorly.

She seems a lot more reasonable.

- Go through the sister to approach.

- That's what I figured, you know?

The wife, she's really heartbroken.

She really loves Charlie.

She doesn't know what she's gonna do without him.

She knows now he's gonna die.

- She's very sick since he's been sick.

She comes in here and she's been dizzy.

- Has she really? - Yeah.

- Oh, wonderful.

Thanks for getting me lunch, Ken.

I haven't eaten yet either you know.

God.

- But you're going home.

You're going home now. - Absolutely.

- I'm going home now too. - I'm going to the bar now.

And that's all.

And who is it?

Taylor has spent time--

- He's very good, he's very realistic.

He sees them every day and he was saying we shouldn't

valvoplasty if this man mentally is not with it.

If he's had a stroke or whatever

that we haven't discovered yet.

- He was on the list for valvoplasty tomorrow and they

canceled him and they're possibly gonna do it on Monday.

You know they're not gonna take him.

There's no way he's stable enough to go down for that.

So,

just have to wait and see.

I need that Blue Book big time,

you can go ahead and see it first.

I'm gonna go down and get something to eat.

- All right, thanks.

Okay, okay.

- He must be upset, his blood pressure's 153.

- That's good though.

At least it might mean his kidneys are a little better.

- The DC.

I think the real problem is we need to

get together with Jim again and sort of

thing about whether there's anything that,

I don't really know why he crumped.

The history of it is much more

consistent with a respiratory thing.

From his heart, he was as maximal as we could make him.

I think he was well diagnosed and he looked pretty good.

I think that he had a high white count and it may be that

just the combination of the sedation and whatever infection

he had, he just gradually went downhill over 36 hour period.

So it was more a respiratory decompensation

but what bothers me is his lungs are so bad

and his heart is so bad, we got his heart

to the best we could get it and we still

couldn't keep him off the ventilator and that

doesn't bode very well for a valvuloplasty.

What that says is even with a valvuloplasty,

I can't get him off the ventilator.

So I think we just need to sorta sit tight for

a day and see what happens because he's got some ATN.

He's non-oliguric probably and it looks

like he's starting to pee now that we've

got everything metabolically under control.

The guy's being ruled out,

there's a whole bunch of other things

but then I think we have to sorta sit down

with Jim and I mean I just, I'd be very

pessimistic that a valvuloplasty would do anything.

But I also don't think I'm gonna get him off the ventilator.

- But to do a valvuloplasty that's not gonna help,

there's not a reason-- - That's what I think.

- Well Jim knows him well, so--

- I think we need to just sorta touch base with

him about that and say okay look, is there any,

because my feeling would be forget it at this point.

But then I think we'd both have to

talk to his wife and explain to her what the situation is.

I think we may get him to the point again

where we can try to extubate him but if we do that,

I'd be in favor of not putting him

back on if he didn't fly probably.

- Yeah, the question is also what--

- Yeah, well I mean I think then it would be hopeless.

There wouldn't be any chance

except sort of prolonging his death.

- I'll talk to her some more today.

- Yeah, talk to Jim and then we'll see.

I don't think we have to make any sudden

moves over the next, you know the weekend.

See what happens. - Thanks, Scott.

The question is gonna come up if

we are able to take out the tube

and see how he does,

what happens if he does not do well?

Certainly if we take it out, it will be our

hope and we'll do everything we possibly

can to see that he does well without it.

But if his breathing becomes a problem off the tube again,

we're gonna have to face the issue of whether

to put the tube back in or not.

Excuse me?

Well that's the question,

I think it can only be used essentially

for the kind of support that he's getting now.

We would hope that in the long run

that he'd be able to manage without it.

If we have to put it back in again,

the question is for what, what sort of a recovery

might he have if he's unable to breathe

except to have the machine do it for him?

Are you gonna be in today?

Uh-huh.

Yes.

Uh-huh.

Yeah.

Well would you rather talk about this sorta stuff in person?

Yeah, all righty.

Well when you come in, why don't you ask

the Unit Coordinator up here in the Intensive Care

Unit to page me and I'll come and we'll speak then.

Because I think the issue that we started to talk

about is one that'll be important to talk about some more.

Well we'll talk about it together, I think

you have to understand as best you can

the medical situation and it's my job to try to

tell you as best I can about that and then together

we'll try to figure out what's the best plan and what to do.

Okay, I'll speak to you later, take care.

- [Scott] I think if we're gonna do a valvuloplasty,

we've gotta do it while he's intubated.

I don't think we oughta try to extubate him.

At the moment it's not clear at all to me

that he could come off the ventilator.

- It's also not clear either that he stands

to benefit a wit from the valvuloplasty.

- Right but those are the questions we gotta,

I guess the other question to put to Jim is

whether, what do you think is the right cardioversion

since we've got his rate controlled but you know,

he may not be able to hold cardioversion and obviously--

- He's been repeatedly in rhythm, right?

- No, he's in AF. - He's in AF now.

- He hasn't been in and out of AF?

- [Nurse] Pretty much been in the last

couple days but he does go in and out.

- He's digitalized now, so his rate is controlled.

Anyway I'm not,

I'm not big on either one of those but--

- We can do more and more technologically but

the question is for what?

Like if he can't be maintained off the respirator,

the big for what becomes sorta written in large letters.

- If we take him off and he doesn't fly,

I'm loath to put him back on. - Yeah, I agree with that.

She's coming in around three and I asked her

to give me a call, so maybe we'll keep the plan

as it is right now, speak to Jim and then

see if we can evolve something towards that.

- Good, okay.

- [Nurse] Okay?

- Can you close her door. - What did he say?

- He says he doesn't think it, it's not,

this is more technology for

unclear benefit. - Okay.

- [Mrs. Sperazza] What do you think?

- [Bill] Well I think that if that tube

could come out, it would be a big step forward.

There's still all the other problems

that haven't gone away since we spoke last time.

But

they've been relatively stable and

that gives us reason to be hopeful I think.

It's still an incredibly grave and difficult situation

but I think if he could come off of that tube,

it would be a big step forward

and clearly if he's gonna be alert at all,

it's gonna be hard for him with that tube in place.

He has to get sedated in order

to have it be tolerable for him.

So that's a difficult situation for him

either to be a little bit more alert but have

the discomfort of it or to be sedated

and not really be able to participate.

- I wouldn't want to see him go back into the sedation.

- No, I wouldn't either. - I really wouldn't.

Because he's not there at all. - Right.

And yet with the tube in place, without the sedation,

he appears to be quite uncomfortable.

So I think

if it can happen safely,

what we want to have happen is what we're making

progress toward again which is to try to get that tube

removed and to get him off of the breathing machine.

If that goes well, we'll have a lot to be thankful for.

We have to also plan if it does happen,

what if he has another breathing problem again?

Are we gonna subject him to the tube

and the machine for a third time?

And we'd have to ask ourselves

what would the purpose of that be?

Hopefully this isn't anything we're gonna face.

Hopefully he'll come off that tube

and we'll see some improvement.

But the fact that he's had so much difficulty,

that there's been so much trouble with

so many different things as we've talked about

makes us have to have our eyes open

even at the same time that we're hopeful

to the possibility that things aren't gonna go well

and I think we have to plan for that at the same time

that we're trying to do everything to

help him move in the right direction.

My own view would be, and hearing from you people

about this is gonna be crucial but my own view would be

that if we're able to get him off the tube successfully,

that gives him the maximum chance of seeing

whether there's any possibility for meaningful recovery.

That we do everything we possibly can

to get him off the tube, we do everything

once he's off the tube to try to keep him

off of it but that we make a decision

not to put the tube back in again if that's

something that you people are comfortable with

and the reason for that would be the notion

that putting the tube back in would be for

no purpose in the sense that if he deteriorates

to the point where he needs it again,

that the likelihood for any meaningful kind of

recovery would be so remote that we'd say

why are we putting him through all of this?

I don't know if, that's a lot to hear

and to think about, I don't know if that

makes sense to you or if you have questions

about it but I think that's the sense that I have.

I've spoken to Dr. Sands, the intern,

I've spoken Dr. Weiss, the attending in

the Medical Intensive Care Unit and I've

spoken to the nursing staff and to Dr. Morgan,

the cardiologist this morning,

I've spoken to all of those people

and they all believe that this would be

a reasonable way to try to maximize the chance for

a meaningful recovery and yet if things don't go well,

to minimize the chance that we're gonna be doing

needless things to him that are gonna be

difficult for him really for no purpose.

We're on the edges of that. - Did you ever have a case

where this was reversed?

- I...

I've been involved in cases where people have looked

desperately sick and where they fooled us and recovered.

But I have to tell you that that

is extremely rare and I don't think that

I've ever been involved with someone as sick

with as many strikes against him as Mr. Sperazza

has where I've seen a meaningful recovery.

But that doesn't mean it doesn't happen.

It's just extremely rare.

We have hope, we are doing what we can to try to see if

that's possible but I think it's at the level where if he

were to recover from this, it would be close to a miracle.

- Really? - Yeah.

- What is the extent of damage right now?

- Well some of that's hard to assess.

The most crucial thing of course is his brain

and how much he's able to recover in terms of

his mental functioning and with the medical complications

that he's had plus with the sedatives he's had to receive,

we can't tell for sure. - So you don't know.

- We don't know.

- What about the other vital organs?

- I could give you a list of the things that are in trouble.

The main things where the difficulty's been

have been his lungs with respiratory failure

which has required the machine and his heart with

congestive heart failure that has complicated the situation.

He's had irregular heart beating,

which has made the heart pump less effectively

and he's got this problem with a blocked heart valve which

we've been going round and round on

whether that may be contributing to this.

The best assessment we have currently is while

that's not good, that that's probably not making

a major contribution to how poorly he's doing.

The other big organ system difficulty is his kidneys.

He's been, his kidneys have been producing

very little urine over the last few days

and added to the list of

questionable failure related to his brain,

respiratory failure.

Heart failure, I think we have to

add kidney failure to the list.

So in that setting, the notion of some sort of

meaningful recovery is extremely remote but you know,

we don't know for sure and that's the reason to

continue to try to support him.

- So if you remove the tube,

that will allow you to do this surgical procedure?

- Well that's looking off to the future.

I think the first step is to see if he can manage

without the tube. - The removal of the tube.

So you're not taking it any further than that.

- No, we were wondering whether that,

what you call the surgical procedure where

they'd use the balloon to open up that heart valve,

whether that might help him to improve his heart function

because everything is so related to everything else

that if we can intervene in one place and make him

a little better, sometimes that can have implications.

But the current think is that that's probably not

a major contributor to how poorly he's doing.

- So the real question is all you want to do,

you want to see what removal of the tube will do

and the secondary question is if he can't survive

without that tube, should you re-insert the tube?

And that's a decision for the family to make, is that right?

- Well it's a decision that we

all have to participate in together.

In a sense you could say it's a medical decision.

If there's no medical hope or the hope is so

remote that it really is just ridiculously unlikely,

can we medically subject him to that?

On the other hand, you could say it's a decision for the

family because it's really making a decision to terminate

life-support because that's what that tube involves.

- It's a gray area here where both of those things

come into play and I think if medically we come to

a decision that from the point of view of your role

in the family looking out for his best interest,

you're comfortable with too, then I think we don't

have to sort out sort of what's on which side of it.

But if we don't see it exactly the same way,

then we can't really move forward with a plan.

We want a plan that everybody feels is

medically best for him but also looking at

the big picture of what he would want and what

you want for him that's consistent with your views.

- Charlie would want to live but

I wouldn't want to see him suffer.

You know?

- [Charlie] When would you need that decision?

- [Bill] It's possible that he may

be moving today or tomorrow towards a point

where we may be able to remove the tube.

I would

ideally like to have, by the time that tube can come out,

it would be nice if we were all at a place where we

were comfortable with a plan of what to do from there.

- If you take out the tube and you see he can make it,

every day is a good day that they live.

- [Bill] Yep, then there's no question.

Then I think there's no, we don't face this--

- That's right.

You know I'll always go by your

decision on what's good for Charlie.

- He's asking you for it. - I know.

I say medically,

he wouldn't want Charlie to suffer.

- [Charlie] No, I know that.

- It's so hard. - It is hard.

- It really is hard.

Don't you think that we could make more of a commitment

once you take the tube out?

- [Bill] I'm not sure I understand.

- Well,

what if you take the tube out and you

find that he more or less rallies around,

anything I say doesn't mean, you know,

she's given me permission to say that's it but you know,

you're gonna do the best for him and I know that

and if there isn't any hope or if he's gonna,

medically you know,

I would never want him to suffer, never.

- I think that if the tube comes out and he shows

an ability to rally with the best that we can do for him,

then we're all comfortable that we'd do everything

to support that and I think if I hear you correctly,

that we're also at a point where if we are able to take

the tube out and yet things take a turn for the worse--

- I don't want the tube back. - It doesn't do him any good.

- But you understand-- - I understand, Charlie.

The tube bothers him.

If he has the tube in him,

then he's gonna be sedated all over again

because he can't tolerate the tube.

- [Bill] If he has the tube in him, it's not living.

- [Mrs. Sperazza] It's not living, he's existing.

- We'd also face the issue then

of sort of where do we go from there?

Because then would we try again to

remove it and put him through that again?

Would we try to keep him on it on a long term basis which

would be miserable for him and as you say from a certain

point of view, right, it's not the kind of life that--

- No, and he wouldn't want it that way either.

Charlie would never want to be like that.

I'm not thinking of me because me,

for me it's lonesome.

He's suffered terribly the last two months.

Maybe, would it have made

a difference if he'd come in sooner?

- [Bill] I don't think that it would have.

No, I really don't.

- He kept saying the last month,

Charlie was a bit of a crybaby, you know that.

He gets scared of everything, every little pain.

He's like the little boy that cried wolf once too often.

He kept saying "I'm gonna die.

"I feel like I'm going crazy."

When we came in here that Sunday morning

at four o'clock in the morning, he was screaming.

I don't know.

I want whatever's best for him.

- [Bill] I think we all want that and I think

we've done a little bit of work toward defining that

in a way that we're all comfortable with together.

I'm gonna be around for the rest of the day

and if you talk some more and want to be in touch again,

they know how to call me.

- [Charlie] The way you feel right now,

the tube has to be removed, we understand that right?

- They're gonna try to do that within the next day anyway.

- [Bill] If things go well in that regard,

we'll be able to remove it.

- In the event you can't remove it, then we'll have to--

- We'll face a different set of issues then.

It's much more difficult, if we can see that

kind of improvement, there's a lot more reason

to be hopeful if he can manage without it.

That's really our hope for the next couple

of days is to move in that direction.

I think if a couple days from now

we're not able to do that, we'll have

to talk some more and take it from there.

But I think it's so complicated that

it's hard enough with the one step at a time approach.

- But you're moving towards the whole issue of

if there's any chance whatsoever, the tube has to be removed

and that hope is as slight as it may be and you can't even

move beyond what will happen once they remove the tube.

You just feel and I would agree with you by the way,

I understand what you're saying that if there's

to be any chance, the tube has to be removed.

- Right. - Okay.

- Dr. Taylor,

what can I say?

I wasn't gonna keep my appointment

Friday but I think I better come in.

- Yeah, I think it would be good to see you.

- He's my friend, he's not only a doctor, he's my friend.

- [Charlie] It's good that you have confidence.

That support. - I do, utmost.

Well thank you Dr. Taylor and I'm sorry I took so much time.

- I'm here for you. - Thank you for explaining.

- [Bill] I'll call you tomorrow

if I don't see you later today.

All right, thank you. - Just stay here.

While you're in the room with him.

- [Mrs. Sperazza] Why don't you ask him now?

- I think he's got anoxic brain damage personally

and I think he's had everything there.

But I mean there's no way to really assess that.

The neurology people wouldn't help us.

We did want to get a head CT to sort of rule

on any structural lesion but I think it's unlikely,

the chances that that's gonna show anything are

I would think one in 10,000.

I think it's mostly the guy with aortic stenosis

who dropped his blood pressure, had a sustained

episode when his blood pressure was running around 70,

had an episode of hypotension when he went on the ventilator

the first time and has a bad ticker and that's all taped.

So I mean, but you could also implicated the Fentanyl,

the Ativan, et cetera, et cetera, et cetera.

So I mean you never know but I mean

you don't breathe up here, you breathe down here.

So this can be all gone and you breathe fine,

so that's the experience up here.

- But he isn't. - But he isn't.

- He could've had an event.

- He could've had an event there but I doubt it.

I think the reason he's not breathing relates more

to the fact that his lungs and his heart are so terrible

and then I think we're gonna have to address

the issue with his wife, what do we do at that point?

- Yeah.

But you haven't give up on the idea that

he might be able to be weaned? - No, no, not yet.

But I think that I probably would still get him,

even if we, I would get him optimal.

The fact that he didn't wean with INB yesterday

doesn't mean that much either because there's increased

resistance to the tubing and the circuitry and so forth.

When we took him off the last time,

the sensorimotor force was only 50 to 100.

Now that may have been one of the reasons

that he failed with the weaning attempt but

on the other hand it's also true that he was

actually doing pretty well for a couple days there.

- Yeah, but now we're seeing

no spontaneous respiratory effort.

That puts it in a little different category maybe.

- Maybe, yeah. - All righty.

- Anyway,

we got a little fine-tuning to do first before we--

- Before you can see. - Yep.

- All righty, thanks. - Okay.

So what's the long range plan,

what do you see as the long range plan?

- We're gonna diverse him back down to his weight of 75,

we're gonna pull out the tubes and give

it a try and it's probably not gonna work.

- [Scott] I agree, no that's exactly--

- [Nurse] We're not gonna re-intubate him?

- Yeah. - We will not re-intubate him.

- I think that's the long range plan.

I mean you know,

it makes me angry, we worked so hard on this guy

and it looks so, so grim, I mean it's just

really discouraging but I don't see any,

we just gotta get him to the point where we optimize

everything and then see if we can get him to fly here.

We've got a few more days.

The big thing is if he doesn't,

if you can't keep him negative kilo,

don't hesitate to start to dobutamine and dopamine back up.

Because he's on a negative inotrope now he wasn't on before.

- His pressures have been real good.

Dopamine alone plus diuretics

will probably stand him in good stead.

The last couple of times he's gotten diuretics--

- Go back and check on him after rounds,

check on his urine output-- - What is it makes him pee?

200 and 200? - Yeah, 200 or 250.

- 250 of diarol. - 250 diarol.

- [Nurse] So pretty much you just have to keep an eye

on his urine output and when it drops below like 160.

He was on a renal organotrope,

we'd like to reconstruct that again.

- [Scott] Keep an eye on his potassium, the other thing.

- [Nurse] And the other thing on the protein is

just the nap but he's got an elevated pattern in the nap.

So just keep an eye on that. - He may have too much,

be a little bit too much sort of where the levels are.

- Okay. - He's been fine.

- [Doctor] The goal is to wean him down,

maybe even drop his breaths one more tonight.

See how he does. - Tonight?

- Maybe, I kind of discouraged that.

And try and get him off tomorrow.

- He should rest overnight. - Yeah.

I talked to the intern, he says he wants to go

and talk to the wife and make sure that she

is really adamant about not re-intubating him.

- He's not to be re-intubated? - That's the plan as of now.

They feel that we've done everything

medically that can be done with this patient.

We dried him out, we buffed him up nutritionally.

He doesn't have an infection right now.

We've done everything we can and the aortic

stenosis may be so severe, we won't be able to--

- [Nurse] You're not gonna take him for the valvuloplasty?

- No. - Why is that?

- I don't believe that he's a good risk at all right now.

- Is he DNR? - Yeah.

No pressers

and as it stands now, we will not re-intubate.

However he's waking up a little bit more

right now and the wife seems really very happy and

I'm just afraid that she'll say

"Well, I do want to re-intubate him now."

So whoever's gonna talk to her today,

Paul, he's gonna talk to her tonight and really

try to explain that we have done everything we could

and he's a 73 year old man with a very severe disease

and does she really want him to live on a ventilator?

Which I think has to be said too.

I think she has to be told in very plain language

what's going on because I'm afraid that

she's gonna see him a little bit more alert,

responding to her and will say "Oh, I do want him to live.

"I do want you to do everything you can."

That just, you know,

came up rather recently.

- [Nurse] Anne-Louise, you have a call on line five.

- [Doctor] She might look at this and say gee,

I want everything done again. - Uh-huh.

- [Nurse] So that, he went from 10 to 12 to 16.

- [Doctor] Do you feel like we

can do anything more for him right now?

- [Bill] No, I think the key is to see how he does and to--

- Extubate him, yeah. - Yeah.

- [Doctor] Because that was definitely

what I got from rounds today.

- I can't imagine that there's much we

have to offer him by getting him weaned

and then having him back on the ventilator.

The question is can he fly? - He has normal looking urine.

So is his blood sugar. - Well he's buffed.

I don't think there's any question that he's dry,

he's almost a little bit too dry.

His blood pressure's been down today.

- How down?

- It's been down as low as 104

and it only goes up to 140 whereas

two days ago it was going up to 200, 180.

And his sodium's up a little bit too, 152.

- Well this may be as good as he

can be to see how he does off the tube.

He's having some spontaneous respirations up to about 10?

- Yeah, pretty poor quality but there's some.

Obviously they're oxygenating him well enough.

His gases have been good,

I don't know if you've seen the blue chart.

His gas is retaining a little bit more CO2 but

besides that the oxygenation's okay, the O2's at about 92%.

Can't get much better than that.

What's his baseline gas?

One of the nurses just asked me, I wasn't sure.

- [Bill] I'd have to check, I think it's around 50-50.

- What you'd expect then, okay.

- In here? - Yeah.

They may throw us out of the room.

- [Mrs. Sperazza] What about the brain scan?

- [Bill] Preliminary result on that scan is that it's okay.

The couldn't get as good a study as they'd

like to get because he was moving a little bit.

But with everything they could see, it looked fine.

As near as we could tell from that,

no problems apparent on that. - Thank God for that.

But the nurse said they're not sedating him as much

because are you thinking of doing the,

getting him off the respirator?

- That's the hope, we're hoping if things continue

to go the way they have been today that maybe by

tomorrow, he'll be able to come off the respirator.

- You think he'll be able to breathe on his own?

- We're not gonna take him off of it

unless there's a good sign that he can.

What'll happen after that, we don't know.

But right now things seem to be in the optimal

situation to maximize the chance that

he will be able to manage off of it

and that's clearly the best time

to work toward getting him off.

- You mean this doesn't mean that he's coming off?

- No, it means he's moving in that direction.

If he has continued improvement the way he has today

that he should be able to have the tube

come out and he off the respirator tomorrow.

But it's still critical enough that it's still

one of these one step at a time kinda situations.

- What does it actually do?

I mean if he comes off of it...

- The respirator is breathing for him.

It's doing the breathing and right now,

he's taking some breaths but

not enough to maintain enough oxygen.

- Oh, I see.

- But yesterday he was taking

virtually no breaths on his own.

So if he can take more and more as

we turn the respirator down and down,

if he takes more and more so that he can maintain

an adequate amount of oxygen in his blood, then we can

turn off the machine but we have to do one step at a time.

We turn the machine down and down and down and watch

and see if he can as it's being turned down respond

by breathing a little bit more and a little bit more.

He has to be able to breathe enough himself

to supply himself with enough oxygen.

- You know what puzzles me, Dr. Taylor?

- He was in here three weeks before that or around that.

Nothing of this could be detected.

- Well what was detected is what was known about

for years which is that he had very serious lung disease.

- Yeah but I mean I'm talking about the heart.

- No his heart actually, it seems that what's

happened is a combination of all these different things

that all together have pushed him to the side of

this critical illness that he's got.

The largest contribution is probably his lungs.

Another contribution is his heart,

another contribution is his kidneys.

All these different things that are in trouble

are all contributing to how poorly he's doing.

But his heart, you know in July just a few months ago,

he had the most sophisticated heart evaluation we know

how to do and at that time his heart did not look too bad.

I mean there were problems, we knew about them.

We needed to assess how bad were they?

But they weren't-- - And the kidneys.

He never had kidney trouble.

- That's really a complication

of everything else getting into trouble.

When the blood pressure goes down,

when the heart isn't pumping effectively, when the--

- Oh you mean these things cause this?

- Yeah. - Oh, I understand.

It just puzzled me because I said if he had these, he's

always, you know how he is about coming for his check-ups.

- Yeah, I know.

- I know a couple times he had back trouble.

- Yeah, that was for the urinary tract infection.

- Nothing to do with his kidneys?

- No. - I see.

- Well I say no, probably that infection

was just in his bladder and certainly

he didn't have any kidney damage from that.

So that seems to be totally unrelated

to the kidneys not working that we've seen recently.

- If he comes off the respirator,

is it something that could recur?

- Could he need the respirator again in terms of--

- In the future?

- Well we don't know, that's a real important question

and that's what we talked about a couple days ago

when we talked about if he comes off of it,

should we subject him to it again if he needs it?

He could be in the situation where

his breathing on his own is inadequate to support his life

and that's the issue that we have to be sure that we're

all comfortable with or as comfortable as you can be

in terms of a decision because the decision that

we talked about a couple days ago was that when he

comes off of that respirator as we hope that he will,

that we'll do everything to maximize the chance

that he can stay off it it and what we had come to together

before was that if he then takes a turn for the worse,

that we're not gonna subject him to the

tube and the respirator again. - I don't wanna do that.

- Well I think it's the right decision from

a medical point of view because I can't imagine

a situation if he did take that sort of a turn for

the worse from which he could have some sort of a recovery.

- No, Charlie wouldn't want that kind of a life.

- Well it's terrible to have to be facing

that issue at the same time that we have the hope

that comes from seeing him doing a little better.

He's taken one step forward.

There are many, many more steps to go in order

for him to have any sort of recovery from this but

it's a wonderful thing-- - But it could be?

- We don't know, that's right.

And before we were looking at even if he had

a day without further problems, that was a plus.

Now he's had a day where he's actually made progress.

Although the hope is as thin as a thread, there's hope

and we're doing everything that can be done to try

to maximize the chance for some sort of a recovery

and as you suggested with the question that you asked,

it's gonna be a critical time,

if we can get him off the machine,

it's a critical time to see if he can

maintain some sort of improvement because if he

takes a turn for the worse at that point,

there probably will be nothing that we can do.

- Well,

I can understand that.

I just don't know how these things happen.

He's like a boy that cried wolf once too often.

He was not a hypochondriac but

he always worried about little things, you know how he was.

But

I never saw him like this, never

and Charlie's been in and out of hospitals.

Never have I seen him like this.

- [Bill] This is the worst it's been, I'm afraid.

- Yeah.

What does Dr. Morgan think, the same as you?

- [Bill] Yeah well he's been very helpful

in terms of making suggestions about adjusting things

from the point of view of helping his heart.

- Well, thank you very much for answering my questions.

- [Bill] I'm gonna see you in the office tomorrow.

- Yeah, I canceled

Charlie's appointment and the

first time I laughed in a long time.

I don't know who the girl I got was.

But I said to her you know, I was gonna cancel.

He's in Intensive Care in the hospital there.

She says does that mean he wants to cancel his appointment?

Well that did me in, you know?

- I said "Yeah, I think it does."

- There's somebody new down in the desk there.

- Must've been.

I didn't think you'd roll him up from

here down there to give him an appointment.

- I roll myself up here to see him instead.

- Right.

Thank you, thank you very much Dr. Taylor.

- You need to go look at him.

I'm told that he's more awake

and indeed was responding to commands.

- Great. - That therapeutic head CT.

- That's right, that's all it takes

and Lorraine really lightened up on the--

- Did you get any mechanics today, or?

- No, he's breathing a little bit.

I didn't ask him to try to do mechanics.

- So we'll do those first thing in the morning then.

- [Scott] I think we're gonna try to

pull his tooth tomorrow.

- Dr. Taylor was just talking to his wife, so.

Hi, Mr. Sperazza.

Good morning.

How are you this morning?

Mr. Sperazza, squeeze my hand.

Squeeze it again, can you squeeze?

Mr. Sperazza, squeeze my hand, squeeze over here.

Good. - Today's the day.

We're gonna get that tube out today.

Big day today.

We're gonna take a listen to your heart and your lungs.

- [Nurse] Administrative answering page on line five.

Administrating answering page on line five.

- [Scott] That really looks better.

It's okay rhythm. - Yes.

- [Nurse] That's what we discussed last night.

- Squeeze my hand.

You know it's me.

You know it's me.

Charlie, you're breathing on your own you know.

What's the matter?

I was downstairs with Dr. Taylor.

Charlie.

Julie's coming in.

Do you wanna see Julie?

Squeeze my hand, Charlie.

Wanna get up and take a walk?

Why is he breathing so heavy?

- He's got secretions in his throat after

we pulled out the tube, so it's gonna take awhile.

We've been suctioning him quite a bit, so.

- Here I am, here I am honey.

I didn't drive in,

Debbie drove me in and she's coming up here.

She was with you last night.

What's the matter, honey?

What's the matter?

I know you don't like that tube up there

but it's better than the one you had in your mouth.

Is he breathe,

breathe, you know?

- He's breathing all right,

he's breathing kind of rapidly, yeah but he's okay.

Taking nice big deep breaths, so.

- Is he? - Yeah.

Looks like I'll have to go on a diet to compete with you.

You wanted to lose weight, now you lost it.

Okay honey, okay.

- I had to go to a trustee dinner last night.

Mitch has these dinners with the trustees.

- Yeah, good eats or not?

- No.

- To show off the professor. - The rubber chicken, no no.

He does this to sorta get the trustees to

be more educated about the hospital but

the topic that we had to discuss was

how to cut the hospital budget three to 5% to

accommodate the decrease in revenues associated with

you know, the lack of healthcare legislation

and the state anticipate a $5 million deficit.

So basically I think the businessmen and I,

the trustees and I were the only

people who manage our own budgets.

I said three to 5%, no problem.

You can cut three to 5% out of virtually

any budget and you won't have any problem.

But that doesn't really solve the problem because

the problem is how do you explain to the American public

that if they want to have everything done for everybody

that it's not only gonna cost what it costs now but it's

gonna go up every year as the number of older people go up.

Two-thirds of all your healthcare costs

are incurred during the final 21 days of life

and I thought that it was two-thirds in the final,

or half in the final year, its even worse than that.

It's two-thirds in the final 21 days

and the problem is we can't tell

who's gonna make it and who's not.

All right so,

shoot. - Mr. Sperazza

had a relatively good day yesterday.

As I gather you heard, there was a period where he

apparently recognized his wife and would respond

to commands to nursing and indeed at one point when I

went in, he would squeeze and release my hand on command

and was attentive

to his name.

So some improvement.

Mr. Sperazza, good morning.

How are you feeling?

Can you squeeze my hand?

Come on, squeeze it hard.

- Did he do it? - Yep.

Can you wiggle your toes, Mr. Sperazza?

Let's see you wiggle your toes.

Great, good work.

- [Female Doctor] You're doing good, Mr. Sperazza.

- You get him out of bed at all?

- Pardon me? - He get out of bed at all?

- Yeah. - He sat in the chair.

- [Bill] Squeeze my hand, Mr. Sperazza.

Mr. Sperazza?

Squeeze my hand, can you do that?

Okay, I'm gonna let you get some rest

and I'll come back to see you again.

- See they're questioning pneumonia in the right bay.

- He should probably actually go on chest PT again

but I'm sure they'll have more to say about that.

- That's when he died last time.

- Yeah.

- Chest PT and he stopped breathing, okay.

- His rate's been a little higher than it was, 38 to 40.

He definitely looks labored.

He looks like he did before

he respiratory arrested last time.

- He's using his belly and stuff?

- Yeah, asynchronous breathing and that kinda stuff.

- So if he just stops breathing,

we just let him stop breathing?

- Mm hmm. - That's so weird.

- Can you squeeze it?

Squeeze my hand?

- I've seen people come back from this.

It's just that the odds are really against him

in terms of his coming back from it and there's still

a possibility that some of this could be metabolic things.

But I have seen some people come back from it.

I mean not,

the chances are with all of his problems,

you're looking at a less than

5% six month survival at the very best

and probably much worse than that.

(phone ringing)

- [Nurse] Medical Intensive Care.

- Okay, just gonna do this side now.

I'm gonna put your oxygen over here.

Can you look at me?

Sorry.

Cough it up.

There's your oxygen.

Now don't shake it off, just keep it right there.

No, don't taste it, it tastes gross.

Keep your tongue in your mouth.

- Ow. - What?

Put your chin up.

This tube hurts, huh? - Yeah.

- Yeah, I know.

Good.

- You know,

this is where sort of clinical epidemiology

and clinical medicine sorta don't intersect.

If you take 1,000 people

and you do these incredibly dangerous interventions to them,

statistically a rare one or two

or three end up with a bad outcome

without any apparent, because it's high risk.

Think about the stuff that we're doing.

Taking away somebody's bone marrow and then

giving them mega-doses of chemotherapy and then

infusing it back into them or giving them six

toxic chemotherapeutic agents in sequence and

watching their white count disappear and sure,

you may get away with it 900 times or 990 times

out of 1,000 but there are gonna be a few people

who are gonna have an incredibly, and the other thing,

the other thing is the way a lot of

chemotherapy is presented to people too.

Take a guy with cell carcinoma in the lungs,

you can say to that person well,

we can double your life expectancy.

We can take you from living three months

with no chemotherapy to living six months

with chemotherapy but for that six months,

you won't be able to swallow anything because your

mouth will be raw, you'll be constantly in the hospital

and infected and, but you'll live twice as long.

But that's not the way it's presented.

You don't present it to a person,

well yeah, we're gonna have you live twice

as long but there's a morbidity associated with

living twice as long or you can live short and sweet and--

- That's a fallacy, it isn't short and sweet.

That man with cell carcinoma

is in marked respiratory distress.

I mean I buy your argument-- - Maybe he gets two months

and then you give him morphine but--

- That may be.

- [Scott] You know--

- But I mean you know,

it's not like you live well with

untreated cancer until the day you die.

You're in horrible pain and worsening respiratory status.

- There may be pain, maybe not, you can treat the pain.

But

no risk is zero, no risk in medicine is zero

and the problem you see is that the culture,

we blind ourselves to all of that stuff because we have to.

Because you have to be a true believer,

you have to believe in this stuff to do it.

If you didn't believe that this stuff would work,

why would you do it?

Faced with Larry Shuleman's dilemma,

a 38 year old woman with three kids,

well you have a choice of doing nothing and watching

her die over the course of a year or doing something--

- [Doctor] For a small chance of survival.

- Right, I mean you know--

- [Doctor] I agree with his choice.

- Well it's hard not to do the other thing

but I think the problem is when you do do that,

then you sometimes end up shortening some people's lives.

So it's a no-win because it's not,

it's manipulating things when you don't

really have an awful lot to manipulate.

In the short term-- - We always--

- Who's got the better prognosis, Mrs. Factor or--

- Or an AIDS patient? - No, this lady.

- [Doctor] In the short term,

Mrs. Factor has a better prognosis.

On the other hand I believe ICUs are

for this lady, not for Mrs. Factor frankly.

- [Scott] But why?

- It's an age-prejudice that I cannot beat.

- That's ageist. - It is ageist.

It isn't age though, it's just her disease.

- [Scott] Right it's an emotional response to the situation.

Here's this 38 year old lady, she's got three kids.

- [Doctor] No no no,

but I don't believe Mrs. Factor can never be cured.

I cannot fix hypertrophic cardiomyopathy and bad lungs.

- Pleural mesothelioma can never be cured either.

- Unless you believe as oncologists believe

that she has a one in a million chance of survival

with this chemo surgery plan for her.

- [Scott] But you see I think it's important--

- You can't say that there's absolutely no hope for her.

- Yes, I would say that there is no hope for her.

In fact that her hope is less than Mrs. Factor

and in fact I think that borders on the same kind of

religious faith that you know, I happen to believe in God.

I have very strong faith in a Supreme Being and yet

I'd have to say that

belief in that is exactly the same sort of blind faith--

- [Doctor] Some mesothelioma patients are cured.

- Yes but much more commonly pleural, sure.

But you have to think about what kind of cases.

They're not pleuro mesotheliomas like this.

- If you really believe that there's no hope,

then this chemo is a farce and cruel

and this ICU stay is a farce and cruel.

- [Scott] Well...

- I can't believe that.

- [Scott] Right, I mean I think--

- I cannot stay up all night with this lady and plug her

and get excited about DIC improving and all this stuff--

- [Scott] You cannot do what you have to do--

- That's right. - If you believe that.

That's exactly what I'm saying, you have to believe in it.

- And I can't actually be a doctor for most of my patients

because you know...

- That's part of the problem.

I think that's part of the problem because

I really do believe that from the moment that diagnosis

was made, it's like in Treasure Island you know when

the old Captain gets handed the black spot,

she got handed the black spot.

She was called and we're minor actors--

- So therefore we shouldn't put active--

- [Scott] I don't say you shouldn't do it.

I think that it's important to recognize that look,

I said put in the swan.

But I think it's important to recognize the reality

of what the situation is. - Oh yeah.

When you first diagnose a patient like her,

you know--

- I think that doctors-- - Your heart sinks.

But you can't just give up on her.

You aren't doing her a favor by giving up on her either.

- See you say it's giving up, you say it's giving up on her.

Well maybe it is giving up on her.

That's one view of it.

That view would suggest that we have something to offer.

But what I'm saying is that it's

not clear we have anything to offer

and in fact what, for the system,

because you know I think I very well might

have done the same thing that Larry did but

I think it's important to recognize

that the system probably shortened her life.

There are some things that are just bigger than us

and doctors in this day and age are extremely

reluctant to say "We can't do anything for that.

"We have no way to help that yet."

I don't know you know, it's hard.

But I mean so much of this stuff is

heavy flail for relatively small to no gain.

I mean a number of people, having built this thing,

I have serious questions as to its utility.

- Oh yeah, I mean you know,

in all the months that I've been here,

three years in a row, there aren't very many patients

who you actually sort of help save their life,

make a major difference.

- We know that everybody who rolls

through that door looks bad, they look bad.

They could go anytime but we can't tell you when.

That's the problem.

I don't know, there's nothing more discouraging than this.

The psychological toll on us and on the family is just

really grim.

- Wish I had somewhere to put this.

I'm gonna put this on top here, is that okay?

Yeah just, yeah can you hold onto that?

Yeah, okay hold it.

Now okay, I can put it up here.

We can take a table with us too.

Here we go.

Okay.

Can you get that? - Yeah.

(patient moans) - What?

Okay.

(loud buzzing)

(chattering)

- [Doctor] Otherwise it's a pretty simple situation.

- [Scott] Right but as with everything you do, there's

the potential that this is gonna be counter-beneficial.

- [Doctor] But then I would settle more on an x-ray.

- [Scott] Agree with that.

- Other issues, substantial metabolic alkalies have

switched, it seemed to be reaching and well-compensated.

- [Nurse] Medical Intensive Care, can I help you?

- Open this bag.

- [Technician] Did you get ahold of the funeral home?

- Yes I did.

Yes I did, thank you very much.

- [Technician] Keep it on that side, just take the sheets.

One, two, three.

Check the tag.

- Oh yeah, it's the right one.

- [Technician] You don't wanna get home and find out--

- Find out I got the wrong body.

Dorothy. - Yep.

- That's good. - Good.

- [Technician] She's gonna have to come down a little bit.

- The zipper doesn't work.

- You got your pins? - No, I don't have anything.

We're gonna go that way. - Okay.

Okay. - Take care, see ya.

- We'll see ya. - All set with your paperwork?

- Yeah, I got all my papers yeah.

Thank you very much, yeah.