Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [74]
Ruth turned to Naomi and said, “Are you ready to lose me?”
Naomi’s eyes filled with tears, and she gripped her mother’s hand.
“Are you ready for me to be gone?” Ruth asked.
Naomi was mute. She began to tremble.
“Are you okay with this, with my wishes?”
Naomi later told us, “It was so confusing to me to have her talking like this.” She explained that her mother was awake, alert, answering the doctor’s questions in full and coherent sentences. “And there was no diagnosis.”
Ruth was transferred directly from the ER to the ICU. It turned out that she had an infection in her blood—sepsis. The doctors infused saline and high doses of antibiotics. Despite this treatment, her blood pressure hovered around 90. Over the next few hours, her breathing became more labored. The doctors in the ICU explained that sepsis can interfere with lung function. Furthermore, Ruth had severe osteoporosis, likely from having had her ovaries removed at a very young age. Despite taking calcium and vitamin D supplements and other medications regularly, her vertebrae had gradually weakened and collapsed. Now, bent over from the changes in her spine, it was hard for her to fully expand her lungs.
Over the next twenty-four hours, Ruth became weaker and weaker. At one point, as the nurse was bathing her mother, Naomi saw a small spot of pus over Ruth’s breastbone.
“My mother was an immaculately kept woman,” Naomi told us. “I looked at the bra that she had worn and saw that it was stained from pus. I pointed this out to the nurse. I didn’t know if she had seen it.” It turned out that this was the source of her infection, because bacteria had migrated from her skin to her sternum and then to her blood.
A senior ICU physician came to talk with Naomi and her stepfather. He explained that Ruth was likely to tire from the effort of breathing and wouldn’t be able to keep breathing effectively without the aid of a ventilator.
“I know you have an advance directive,” he said to Ruth, “but we would like to put you on a ventilator as a temporary measure, until we clear the infection.”
Ruth shook her head no. “I don’t want to be a vegetable,” she declared. “I want to be alive and active, or gone.”
The doctor reiterated that the intervention would last only until the infection could be controlled. As soon as the antibiotics took effect and her blood pressure and oxygen rose to safe ranges, they would take her off the ventilator. Ruth refused again.
Naomi and her stepfather accompanied the physician into the hall outside the room.
“She’ll probably die if she doesn’t agree to this,” he said.
“I understand,” Naomi replied. “I’ll do everything I can to try and convince her.”
Naomi returned to the room and spoke again with her mother. But Ruth remained adamant. “I don’t want to be on a breathing machine,” she said. “And I know where this can lead. If they need to keep me on it, then they’ll transfer me to some chronic care facility. I don’t want to live in rehab. You know that I want to be alive and active or gone.”
An hour later, a middle-aged nurse who had been attending to Ruth came in.
“I’m just going to straighten up a little here,” the nurse said. She took away a cup of water and prepared a new one with a fresh straw. Naomi’s husband had brought pictures of the grandchildren, which were arranged on the table next to her bed. “Beautiful children,” the nurse said, looking at the photographs. Ruth nodded and smiled.
“You know, my father was in a similar situation to yours,” the nurse said to Ruth and Naomi. “He was very sick, and had made it clear to us that he didn’t want to live if it meant being sustained artificially.” The nurse paused. “He had a problem with his heart. The doctors said his heart would improve, but they needed to make sure he was getting enough oxygen to let it heal.” The nurse told them that