Chapter
Right To Die
“But Professor,” asked the medical student, “what about his recurrent migraines?”
“Not relevant,” replied the Professor in clipped tones, “this is cardiology. Pain which occurs as a result of labyrinthitis, otitis, sinusitis, rhinitis, retinitis, neuritis, meningitis, encephalitis, arteritis or choroiditis, are not our concern. If it is posing a risk to his prognosis, book a consultation with the relevant department, otherwise give him an aspirin.”
The professor seemed proud of his ability to enumerate some of the mechanisms of severe headaches, even though they were not ‘his department’.
“He really is in a lot of pain though,” continued the student, irking the professor further.
“I am not interested,” replied the professor in an emphatic monotone. “It is time for us to move on to the mitral incompetence in bed three.”
The student developed a somewhat sorrowful look, as though he felt uncomfortable leaving the pale, sweating patient, lying in bed, propped up on pillows, elbows resting on drawn up knees. The headache was bad enough for the patient to be pressing on the sides of his head, clenching his eyelids, his forehead wrinkled.
We passed on to the next bed where the mitral incompetence lay dying. He was lying in a forest of tubes and wires: two intravenous lines, oxygen mask, cardiac monitor, oxygen monitor, urinary catheter, nasogastric tube. He was a little frightening to behold, very frightening in fact. As the intern, I was charged with keeping him alive, supposedly in the forlorn hope that his name would come up in the lottery of organ transplants. This was not an easy balance to maintain, between the tightrope of heart failure, fluid overload, and electrolyte imbalance, to say nothing of trying to keep him vaguely comfortable and staving off the sensation he continually experienced that he was drowning.
“Oh, please doctor,” whimpered the patient, clutching ineffectually at the professor’s hand, “please, let me die. I’m so uncomfortable, it’s horrible. I can’t get my breath. I don’t want to carry on like this…”
“Results,” snapped the prof irritably, withdrawing his hand, and successfully ignoring the entreaties of the dying man.
“Sodium 125, potassium 3.7, urea 8.1, creatinine 108,” I recited tonelessly reading from the results sheets.
“Hmmmph,” grumbled the Prof,” you’ve over diuresed him, again.”
“I know,” I replied, “but if we reduce his diuretics, he gets unbearably dyspnoeic. As it is, he’s on forty percent oxygen.
“I think he needs inotropic support,” added Brodyn, me fellow intern.
“Oh, you do, do you,” replied Prof sarcastically, “and which ICU do you think is going to offer a bed to a case like this, with no prognosis?”
We stared stolidly at Prof. This was one of those frequent moments of discomfort, when I didn’t know what to say. They usually added to my existing feelings of inadequacy.
“Maybe morphine,” ventured the student bravely.
“Morphine!” Exclaimed Prof. “And risk reducing his respiratory effort?”
“Well, if he has no prognosis, it wouldn’t matter, and he would feel a lot better in the interim,” replied the student.
‘He’s a lot bolder than I,” I thought.
“It may make him feel better,” blurted the Prof curtly, “but the reduced respiratory effort would result in a greater risk of demise.”
The student wasn’t brave enough to reply further.
“Book him for a repeat angiogram,” continued the Prof. “It will tell us how bad his ejection fraction is now.”
“But he already qualifies for the transplant list,” Brodyn pointed out. “Why do we need another angio?”
“Because I said so,” exclaimed Prof. “I wish to put him in my series on deteriorating left ventricular function in patients awaiting transplant. There are almost sufficient cases in the series for publication.”
The extra work to organize unnecessary, and invasive, angiogram was frustrating for the interns. I exchanged expressive looks with Brodyn. His surreptitious mischievous grin, indicating that a) he thought the professor an idiot, and b) he would intervene with a Brodyn manoeuvre.
(Brodyn manoeuvres were decisive, expressive, effective, and always unauthorised procedures or comments, which tended to benefit the patients but, being frequently of a mildly belligerent nature, they tended to irritate the professors and consultants. As Brodyn, unlike me, was intellectually brilliant, he seldom suffered repercussions. The Professors and consultants seemed always a little reticent in the face of Brodyn’s encylcopaedic knowledge, and quick tongue.)
We continued our cardiology ward round, reviewing one doomed victim after the next. After the round, I sat in the interns’ office and called the angio suite to book a slot for Mr Decapulan, the patient with the mitral incompetence.
Brodyn, who looked after the other half of the ward during the day, was on call that night. Before I left that evening, we went on our usual walk together around my half of the ward. This ‘handover’ round, gave the intern on cold cover a brief update on each of the patients in case he should be called to any night time emergencies. As we discussed Mr Decapulan, he once again pleaded with us, in panting spurts of speech, to end his suffering by letting him die.
“Fret not my dear sir,” said Brodyn. “I will be here all night and will ensure that you are quite comfortable.”
I said goodbye to Brodyn a bit later and left for home, with the free feeling of shed responsibility, and the rare, blissful prospect of a whole night of uninterrupted sleep.
The next morning on the ward round, Prof was his normal pleasant self. When we got to Mr Decapulan’s bed, it was empty. Prof looked at me and stated curtly with a small nod of his head, “you managed to schedule an early angiogram. Very efficient.”
“Um, actually,” I replied hesitantly (I wasn’t as precise and emphatic as Brodyn). “Well, uh, he, um, died.”
“Died!” exclaimed Prof. “Died? Died, of what, exactly?”
“Death,” I was supposed to reply, having been primed by Brodyn, but I was not brave enough.
“Um,” I continued, “it seems that he had a cardiac arrest in the night.”
“Who was on call?” demanded the Prof, switching his stern gaze repeatedly between the two of us.
“I was,” announced Brodyn without hesitation.
“Well, doctor,” said the Prof, “can you enlighten us further on what occurred?”
“The patient was uncomfortably dyspnoeic, and had a poor response to increased oxygen. Increasing his position form semi-fowlers to fowlers and even high fowlers failed to give him any relief. As he was already hyponatraemic, it wasn’t possible to make further use of diuretics. Inotropic support would have been useful, but, as we know, ICU had no bed for him. As a result I administered a titrated dose of iv morphine until the patient announced that he felt comfortable. His oxygen saturation did drop about ten percent but remained above eighty. About half an hour later he developed a sudden VF and required resuscitation. The VF was refractive to repeated defibrillation and terminated in a cardiac arrest. The resuscitation was declared unsuccessful after forty-five minutes.
By now Prof was red in the face.
“You! You gave him morphine!” he sputtered angrily, his face reddening. “I told you yesterday that morphine would kill him.” “In the face of zero prognosis,” Brodyn continued calmly, “the risk benefit analysis of utilizing a potentially lethal therapeutic option, such as an opiate, to relieve the discomfort occasioned by the dyspnoea, was decided in favour of the opiate.”
“Was decided, was decided! Was decided by who?” demanded the Prof. A small fleck of spittle showed itself on the side of the Prof’s mouth.
“By whom?” corrected Brodyn, no doubt to irritate the Prof still further.
“Whatever,” erupted Prof, spittle now foaming at the corners of his mouth. “What I want to know is, who killed my patient?”
“That would be me,” replied Brodyn, with an innocent smile.
“But, but,” demanded the Prof, disbelief diluting the anger displayed on face, “what about the angio. You did the angiogram, didn’t you?” he pleaded, turning to me.
“I did book it,” I replied, “for 11:30 this morning.”
“I better phone and cancel it,” I added, as a seemingly irrelevant afterthought.
Prof turned back to Brodyn, still red in the face.
“I’ll report this,” he exclaimed. “I’ll have you before the ethics committee. I’ll have your hide for this. You can’t go round killing off my patients. Euthanasia is illegal you know.”
“I have retained a copy of the entire folder,” replied Brodyn, still calm. I don’t know how he remained so stoic.
“I will of course be explaining all to the ethics committee,” continued Brodyn, in lecture mode now, “that this patient, in extreme discomfort, and with no prognosis, was about to be subjected to an invasive procedure, utilizing extensive hospital resources, for the sole purpose of obtaining data for publication.”
The red face Prof was staring at Brodyn in wide-eyed disbelief.
“And further, that this was not part of a formal clinical trial setting,” Brodyn seemed unstoppable now.
“And that the patient’s consent would have been coerced,” he concluded.
I looked guiltily at the floor, as the consent form would have been signed at my behest, and would have been done after, at best, the usual cursory explanation to the patient.
The Prof was too startled to reply. He simply got redder in the face, turned on his heel, and stomped his way out of the ward.
The ethics committee never summoned Brodyn to account for his actions.
“Pity,” said Brodyn much later, “would have been fun to do a bit of ‘explaining’.”
Right To Die
“But Professor,” asked the medical student, “what about his recurrent migraines?”
“Not relevant,” replied the Professor in clipped tones, “this is cardiology. Pain which occurs as a result of labyrinthitis, otitis, sinusitis, rhinitis, retinitis, neuritis, meningitis, encephalitis, arteritis or choroiditis, are not our concern. If it is posing a risk to his prognosis, book a consultation with the relevant department, otherwise give him an aspirin.”
The professor seemed proud of his ability to enumerate some of the mechanisms of severe headaches, even though they were not ‘his department’.
“He really is in a lot of pain though,” continued the student, irking the professor further.
“I am not interested,” replied the professor in an emphatic monotone. “It is time for us to move on to the mitral incompetence in bed three.”
The student developed a somewhat sorrowful look, as though he felt uncomfortable leaving the pale, sweating patient, lying in bed, propped up on pillows, elbows resting on drawn up knees. The headache was bad enough for the patient to be pressing on the sides of his head, clenching his eyelids, his forehead wrinkled.
We passed on to the next bed where the mitral incompetence lay dying. He was lying in a forest of tubes and wires: two intravenous lines, oxygen mask, cardiac monitor, oxygen monitor, urinary catheter, nasogastric tube. He was a little frightening to behold, very frightening in fact. As the intern, I was charged with keeping him alive, supposedly in the forlorn hope that his name would come up in the lottery of organ transplants. This was not an easy balance to maintain, between the tightrope of heart failure, fluid overload, and electrolyte imbalance, to say nothing of trying to keep him vaguely comfortable and staving off the sensation he continually experienced that he was drowning.
“Oh, please doctor,” whimpered the patient, clutching ineffectually at the professor’s hand, “please, let me die. I’m so uncomfortable, it’s horrible. I can’t get my breath. I don’t want to carry on like this…”
“Results,” snapped the prof irritably, withdrawing his hand, and successfully ignoring the entreaties of the dying man.
“Sodium 125, potassium 3.7, urea 8.1, creatinine 108,” I recited tonelessly reading from the results sheets.
“Hmmmph,” grumbled the Prof,” you’ve over diuresed him, again.”
“I know,” I replied, “but if we reduce his diuretics, he gets unbearably dyspnoeic. As it is, he’s on forty percent oxygen.
“I think he needs inotropic support,” added Brodyn, me fellow intern.
“Oh, you do, do you,” replied Prof sarcastically, “and which ICU do you think is going to offer a bed to a case like this, with no prognosis?”
We stared stolidly at Prof. This was one of those frequent moments of discomfort, when I didn’t know what to say. They usually added to my existing feelings of inadequacy.
“Maybe morphine,” ventured the student bravely.
“Morphine!” Exclaimed Prof. “And risk reducing his respiratory effort?”
“Well, if he has no prognosis, it wouldn’t matter, and he would feel a lot better in the interim,” replied the student.
‘He’s a lot bolder than I,” I thought.
“It may make him feel better,” blurted the Prof curtly, “but the reduced respiratory effort would result in a greater risk of demise.”
The student wasn’t brave enough to reply further.
“Book him for a repeat angiogram,” continued the Prof. “It will tell us how bad his ejection fraction is now.”
“But he already qualifies for the transplant list,” Brodyn pointed out. “Why do we need another angio?”
“Because I said so,” exclaimed Prof. “I wish to put him in my series on deteriorating left ventricular function in patients awaiting transplant. There are almost sufficient cases in the series for publication.”
The extra work to organize unnecessary, and invasive, angiogram was frustrating for the interns. I exchanged expressive looks with Brodyn. His surreptitious mischievous grin, indicating that a) he thought the professor an idiot, and b) he would intervene with a Brodyn manoeuvre.
(Brodyn manoeuvres were decisive, expressive, effective, and always unauthorised procedures or comments, which tended to benefit the patients but, being frequently of a mildly belligerent nature, they tended to irritate the professors and consultants. As Brodyn, unlike me, was intellectually brilliant, he seldom suffered repercussions. The Professors and consultants seemed always a little reticent in the face of Brodyn’s encylcopaedic knowledge, and quick tongue.)
We continued our cardiology ward round, reviewing one doomed victim after the next. After the round, I sat in the interns’ office and called the angio suite to book a slot for Mr Decapulan, the patient with the mitral incompetence.
Brodyn, who looked after the other half of the ward during the day, was on call that night. Before I left that evening, we went on our usual walk together around my half of the ward. This ‘handover’ round, gave the intern on cold cover a brief update on each of the patients in case he should be called to any night time emergencies. As we discussed Mr Decapulan, he once again pleaded with us, in panting spurts of speech, to end his suffering by letting him die.
“Fret not my dear sir,” said Brodyn. “I will be here all night and will ensure that you are quite comfortable.”
I said goodbye to Brodyn a bit later and left for home, with the free feeling of shed responsibility, and the rare, blissful prospect of a whole night of uninterrupted sleep.
The next morning on the ward round, Prof was his normal pleasant self. When we got to Mr Decapulan’s bed, it was empty. Prof looked at me and stated curtly with a small nod of his head, “you managed to schedule an early angiogram. Very efficient.”
“Um, actually,” I replied hesitantly (I wasn’t as precise and emphatic as Brodyn). “Well, uh, he, um, died.”
“Died!” exclaimed Prof. “Died? Died, of what, exactly?”
“Death,” I was supposed to reply, having been primed by Brodyn, but I was not brave enough.
“Um,” I continued, “it seems that he had a cardiac arrest in the night.”
“Who was on call?” demanded the Prof, switching his stern gaze repeatedly between the two of us.
“I was,” announced Brodyn without hesitation.
“Well, doctor,” said the Prof, “can you enlighten us further on what occurred?”
“The patient was uncomfortably dyspnoeic, and had a poor response to increased oxygen. Increasing his position form semi-fowlers to fowlers and even high fowlers failed to give him any relief. As he was already hyponatraemic, it wasn’t possible to make further use of diuretics. Inotropic support would have been useful, but, as we know, ICU had no bed for him. As a result I administered a titrated dose of iv morphine until the patient announced that he felt comfortable. His oxygen saturation did drop about ten percent but remained above eighty. About half an hour later he developed a sudden VF and required resuscitation. The VF was refractive to repeated defibrillation and terminated in a cardiac arrest. The resuscitation was declared unsuccessful after forty-five minutes.
By now Prof was red in the face.
“You! You gave him morphine!” he sputtered angrily, his face reddening. “I told you yesterday that morphine would kill him.” “In the face of zero prognosis,” Brodyn continued calmly, “the risk benefit analysis of utilizing a potentially lethal therapeutic option, such as an opiate, to relieve the discomfort occasioned by the dyspnoea, was decided in favour of the opiate.”
“Was decided, was decided! Was decided by who?” demanded the Prof. A small fleck of spittle showed itself on the side of the Prof’s mouth.
“By whom?” corrected Brodyn, no doubt to irritate the Prof still further.
“Whatever,” erupted Prof, spittle now foaming at the corners of his mouth. “What I want to know is, who killed my patient?”
“That would be me,” replied Brodyn, with an innocent smile.
“But, but,” demanded the Prof, disbelief diluting the anger displayed on face, “what about the angio. You did the angiogram, didn’t you?” he pleaded, turning to me.
“I did book it,” I replied, “for 11:30 this morning.”
“I better phone and cancel it,” I added, as a seemingly irrelevant afterthought.
Prof turned back to Brodyn, still red in the face.
“I’ll report this,” he exclaimed. “I’ll have you before the ethics committee. I’ll have your hide for this. You can’t go round killing off my patients. Euthanasia is illegal you know.”
“I have retained a copy of the entire folder,” replied Brodyn, still calm. I don’t know how he remained so stoic.
“I will of course be explaining all to the ethics committee,” continued Brodyn, in lecture mode now, “that this patient, in extreme discomfort, and with no prognosis, was about to be subjected to an invasive procedure, utilizing extensive hospital resources, for the sole purpose of obtaining data for publication.”
The red face Prof was staring at Brodyn in wide-eyed disbelief.
“And further, that this was not part of a formal clinical trial setting,” Brodyn seemed unstoppable now.
“And that the patient’s consent would have been coerced,” he concluded.
I looked guiltily at the floor, as the consent form would have been signed at my behest, and would have been done after, at best, the usual cursory explanation to the patient.
The Prof was too startled to reply. He simply got redder in the face, turned on his heel, and stomped his way out of the ward.
The ethics committee never summoned Brodyn to account for his actions.
“Pity,” said Brodyn much later, “would have been fun to do a bit of ‘explaining’.”
