Off Beat! (02): Coping with unhappy choices

By John B. Monteiro
Bellevision Media Network

“Is there no hope?”,  the sick man said,
The silent doctor shook his head,
And took his leave with signs of sorrow,
Despairing of his fee tomorrow.

-   John Gay, English poet (1688-1732).

 

Since John Gay’s time, there is an increasing public perception that doctors have progressively deteriorated into money-minting machines sans soul or emotions. There are exceptions, of course. One of them, of Indian origin and now settled in USA, is  Dr. James Abraham, MD, FACP,  Bonnie Wells Wilson Distinguished Professor, Chief of Oncology and Medical Director of Mary Babb Randolph Cancer Center, West Virginia University, USA.  He frequently writes very readable and heart-touching articles in The Week Health, issued as supplement with The Week. The one in the issue of May 6, 2012, titled “Can choices make us happy?” brings out the dilemma of doctors with a soul. While the article can be summerised and presented, it is largely excerpted here to retain its original flavour.

 

Donavan was a 54-year-old car salesman at the local Ford dealership. When he started his job as a fresh high school graduate, the choices he could offer were limited to a Fairlane or a Torino. IBut the range and array of vehicles he can offer his customers have exploded over the past 30 years. Watching his customers struggle through the long list of choices often amused him.

 

He was adhering to the good old American philosophy: choices make people happy!!

 

I met Donavan during one of my rounds in the intensive care unit. His brother Mike was on a ventilator. He was fighting for his life. The breathing machine unswervingly delivered the pre-calculated amount of oxygen. He was deeply sedated and did not respond to any stimuli. He had multiple lines going through his arteries and veins, measuring blood pressure and oxygen levels. He had more than nine bags of medicines hanging on the IV pole.

 

“How is Mike doing?” I asked the ICU nurse who was busy adjusting the blood pressure medicines.

 

“He is fully vent dependent and requires multiple pressers to maintain his blood pressure.”

 

The ICU doctor gave me an update of his condition. Over the past one week his condition had been steadily deteriorating.
“Doc, what do you think..?” Donavan had not slept for three days and his eyelids were puffy.

 

“Let’s discuss this in the family room.”

 

Mike was not just his younger brother; they were best buddies. Mike and Donavan were raised by a single mother. Their dad had died at a young age from alcoholism. Mike always looked up to Donavan for answers. Mike had been complaining about upset stomach for the past six months. He had been losing weight. Donavan thought it was due to a recent divorce that Mike had gone through. Mike’s wife of 20 years had walked out of their marriage. Mike often skipped meals and was popping too many antacid pills. He changed the antacid brands depending on the commercials he saw.

 

Mike was diagnosed with advanced stomach cancer about three weeks earlier.  The PET scan showed that the cancer had already spread to the liver and lungs. The local oncologist did not give him much hope, so he came to the university hospital. When we saw him, he had developed pneumonia, probably by aspirating food into his lungs.  The pneumonia rapidly led to respiratory failure.

 

I had long discussions with Donavan. He insisted that we transfer Mike to the ICU and intubate. But his condition worsened. We talked to Donavan many times about stopping the aggressive treatment, but he adamantly refused. I pulled the chair close to the table and sat on the same side as Donavan and Mike’s son. The junior doctors stood around us.

 

“Mr Donavan, your brother has not made any improvement in the past several days.” I paused for a moment. “He is still running a high fever even on multiple antibiotics. His blood pressure is maintained on two different medicines and he is completely dependent on the machine for breathing.” I summarised his medical condition.

 

“What options do we have here doc?” asked Donavan.

 

“We have only limited choices….” I was talking to a man who grew up in a culture of innumerable options. When faced with the inevitable truth, I always believe in being honest.

 

Truly speaking, Mike had no choice. He was going to die soon. The machine was keeping him alive, but it was only a matter of time. “I don’t think he will come out of the breathing machine.”

 

“Doc, I can’t believe that we have no options,” Donavan mumbled.

 

“Can we take him somewhere else?” It was Mike’s son. He looked at his uncle’s face for answers. Tears poured down his face. He was about 21 years old.

 

“You can always take him wherever you prefer to.” I handed him a tissue. “But I wouldn’t recommend that.”

 

Here I was again, limiting their choices.

 

Coffee shops to colleges thrive on offering choices. But when it comes to life and death, unfortunately the choices are very limited.

 

Donavan, who promised his mother that he will protect his younger brother, broke down into tears. He sobbed uncontrollably. It was hard to watch a grown up man crying.

 

I have done this a thousand times, delivering the certainty of death. I am still not good at it.

 

Mike’s son came over and hugged Donavan.

 

Donavan taught his nephew the importance of making the right choices. Now his father was facing death and the doctor was not giving him any choice.

 

I talked to the family for about an hour. We talked about the pros and cons of continuing the treatment versus stopping it, one antibiotic versus another, different tests, different treatments for cancer. In a way I was providing them with a list of choices and honouring the American tradition. I was asking them to make the final decision. But in this situation, choices had only limited relevance.

 

As a car salesman, Donavan thrived on providing choices.

 

But he did something “un-American”.

 

“Doc, we trust you. What do you think we should do?”

 

After weighing all the options, Donavan was asking me to help him make the final decision. He was relinquishing his individual right to make that decision.

 

I looked at his son. He laid his head on the table and did not look up. Mike must have been an excellent father who took his son for baseball games and fishing trips.

 

“If he was my family member, I will not make him suffer any more.” I paused for a moment.

 

I walked out of the family room. The weight of the decision....Choices may not always make us happy.

 

Going beyond Dr. Abraham, Donovan, Mike and irreversible terminal cancer, we have many situations in our daily lives where we have to weigh options and choose one that makes us happy. Take, for instance, the decision to migrate to a western country or to Australia-New Zealand, leaving behind aged parents to fend for themselves. Or again, even while living in the home country, the old parents become a burden and dumped in the old age home and even forget about paying their monthly charges. What about denying adult children the right to select their mates for life? Or impose the stream of education youngsters can opt for – medicine and engineering imposed on youngsters - who would be happy going in for liberal arts?  There are so many other situations where options determine happiness or misery.

 

How do we cope with them? Chew on this. And share!

 

 

 

 

John B. Monteiro, author and journalist, is editor of his website www.welcometoreason.com (Interactive Cerebral Challenger) with instant response format. Try responding!