The Making of a Nurse (23 page)

The next morning, I was taken aback when her night nurse told me that the Rabbi had visited her, late at night after sundown, at the end of the Sabbath. “He asked her for a donation to the synagogue. He said he would say extra prayers for her and asked for a cheque for that, too.”

“I guess she can spend her money this way,” I said slowly, thinking it over.

“Yeah, but I don’t feel right about it,” the other nurse said, and explained her uneasiness. “She’s vulnerable. It’s like she’s at his mercy. The Rabbi was worried that her cheque might not be accepted at the bank, so he wanted me to witness her signature, but I refused.”

“Yes, it does sound like they might be preying on her, as well as praying for her,” I agreed. “It doesn’t sit right with me, either.”

“She’s angry at me for not signing and feels her independence has been taken away. She told me you would sign it because you’re Jewish, too.”

But Mrs. Green didn’t get a chance to speak with me about the matter because that day, once again, her condition suddenly worsened. This time her heart went into atrial fibrillation that caused her blood pressure to drop. We had to shock her heart many times that day and eventually managed to bring it back to a normal sinus rhythm. But there were ominous beats on the monitor, and I brought the crash cart into the room, just in case.

During rounds, Dr. Sandor put out a question that made us all think. Which was the bigger fear if we were to be hospitalized – that too much would be done or too little? That we would be over-treated with unnecessary tests and procedures or under-treated and important things missed? Most of the doctors said too little and most of the nurses said too much. Perhaps we trusted the system more than we should, but if so, then they, not enough.

Dr. Sandor has always been committed to making us scrupulously accountable in our practice. He has raised many questions
over the years as well as a few eyebrows. He infuriates us, challenges us, and always makes us think. “Do you remember Mrs. Ford?” I asked him recently.

“That was an important case.” He looked at me intently to assess if I realized just how important.

It had happened years ago when I was still fairly new to the
ICU
but even then I recognized its significance. Mrs. Ford was a sixty-five-year-old woman with
ALS
*
, also called Lou Gehrig’s disease, a slow, debilitating neurological disease that left her body paralyzed, but her mind awake. She was “locked-in,” unable to move or speak, yet fully aware of her situation. Dr. Sandor told her she could choose the date and time of her death. Her family gathered around her bed. She said goodbye to everyone. We started a morphine infusion until she was drowsy and at the same time slowly decreased the ventilator settings and the oxygen until she became comatose and then died.

“How were we able to do that for her?” I asked. To this day, I’ve never really understood it. It seemed so radical to assist a patient to choose the day and conditions of her death and to watch her go from fully awake to drowsy, to unresponsive, to dead in a matter of hours.

Dr. Sandor calmly explained. “In the case of Mrs. Ford’s death, we were, as always, guided by the patient’s wishes. At all times, we kept uppermost in mind the reasons we were giving the narcotic and we stayed focused on our goal of maintaining the patient’s dignity and comfort.”

“I’M CONCERNED THAT
your patient is allowing a religious authority to make decisions for her,” Dr. Sandor expressed to me privately, after rounds, away from Mrs. Green’s bedside. We were sitting at a long boardroom table in the glassed-in fishbowl, a.k.a. the “think-tank” behind the nurses’ station.

“She did express her wishes, when she was last able to communicate,” I said.

“Yes, but are they truly hers or is she abdicating her autonomy to the Rabbi?”

What I had finally figured out was that Mrs. Green did not believe in the hallowed concept of individual autonomy. To her, religious law had the utmost importance, far greater than a human’s puny will or personal preference. We had to back right off, but not until Dr. Sandor gave it one more try. He had to ascertain that these were indeed Mrs. Green’s wishes. There wasn’t much time left. We both knew that the next crisis was imminent.

We went back out to speak with Mr. Green. The Rabbi stood with him outside Mrs. Green’s room. They did not wish to meet with the rest of the team in the “quiet room,” but would only stand outside Mrs. Green’s room and talk with Dr. Sandor, with me listening in. I understood that they would never speak to me directly, as it is forbidden for a man to address a woman other than one’s wife. The Rabbi stated his position to Dr. Sandor. “The Jewish view is that we are to be wise and prudent stewards of our bodies,” he explained, palms open, his hands outstretched. “It is our greatest endowment from Ha Shem.”

“It is not medically indicated to offer anything further to your wife,” Dr. Sandor said to Mr. Green, crossing his arms across his chest and widening his stance. “There is no chance for survival should she have another cardiac arrest.”

The Rabbi spoke. “If there is a straightforward and obvious treatment, it must be carried out.”

“We do not wish to impose harmful, painful procedures upon your wife,” Dr. Sandor said, again to Mr. Green, “because, first of all, they won’t be of any benefit and second, it would be inhumane to do so.”

“Some tortures are worth enduring,” the Rabbi said gently.

I watched Dr. Sandor as the Rabbi spoke. He looked good, and fit, but he’d aged. This work had aged us both. He continued, still addressing Mr. Green. “In my medical opinion it would be wrong and useless to attempt to resuscitate your wife if she experiences another cardiac arrest.”

“Is she is on life support?” the Rabbi asked.

“Yes. If any of the machines or medications she is on were to be removed, she would die.”

“Is she receiving sedation? She needs to be alert enough to hear the prayers.”

Dr. Sandor tried to hide his exasperation. “The main point here is that we need to clarify the plan in the event of a cardiac arrest. My opinion is there is no medical reason to perform
CPR
on your wife. It will not benefit her in any way.”

“Are you saying there is no possibility whatsoever that it would bring her back?” the Rabbi asked.

“It is highly unlikely.”

“But didn’t you say she has pneumonia? Can’t that be cured with antibiotics? Hasn’t she recovered from similar crises before? Are you basing your recommendations on what
you
would want? It is not within our moral jurisdiction to decide if a life has no quality, or is not worth living.” The Rabbi pursed his lips in consternation and glanced at me. “We, the Jewish people, believe in a sacred reverence for all life. Even this nurse knows that.”

This was my chance to jump into the fray. I glanced at Mr. Green and he averted his eyes and turned to the Rabbi, who looked at Dr. Sandor. “From what I understand,
Halacha –
Jewish law – prohibits us from shortening the life, but what does it say about prolonging it unnecessarily?”

“You should know better, Tilda,” he said, and invoked again the highest imperative, which is the rescue of a human life, something to be attempted at all costs.

Finally, I was beginning to get it. To them, suffering was worth it for even another moment of life. Mr. Green’s wishes, his wife’s wishes, were irrelevant. All that mattered were the wishes of “Ha Shem” as the Rabbi understood them.

“Regardless of what we do or don’t do, Mrs. Green is going to die,” Dr. Sandor said.

“That is not for you to decree.” The Rabbi turned and walked away and Mr. Green followed after him. I stood alone in the hall with Dr. Sandor. It is sometimes hard to read his feelings, but there was no mistaking them now; after that encounter, he looked sad.

“Aha,” I said, putting my arm around him, “you
do
have feelings. I just saw them.” I detected a tiny smile. “You know what, Imré, I have come around to your point of view. I think there are times when what we do is futile.”

“I’m shocked, Tilda! I thought you didn’t believe in the f-word,” he teased me back.

“Perhaps the antidote to futility is meaning. If something has meaning to someone, that redeems it.”

“Well, you’re too late in coming around, Tilda. Ethicists don’t even use the term
futile
any more because it is too value-laden and open to interpretation. We differentiate between physiological futility and quality of life futility,” he explained, always the teacher.

“I understand the Green family now,” I said, eager to draw to an end this complicated discussion, “but it’s still hard to be her nurse.”

It was during that fifth
ICU
admission that Mrs. Green had a final cardiac arrest. We were unable to revive her after a resuscitation attempt that went on for more than two hours, during which we did everything we could until there was nothing left to do. But at least, all the time that we were trying, we felt resolved about what we were doing as we knew that these were her wishes.

“We must not tamper with the soul,” she told me in one of her last moments. “Quality of life is not the issue. Life is the most important thing.”

MY UNDERSTANDING
of Mrs. Green’s choice helped me accept it. I also had a deeper understanding of Mrs. Ford’s. However, just when I thought I was getting a handle on these complex moral, ethical, and spiritual matters, I heard a story that raised new questions. I was walking past the nurses’ station when Louise saw me and called out, “Hey, Tilda!” Louise must be fifty, but yoga classes and good genes make her look thirty. Petite and delicate, she leaned over the countertop and grabbed my hands with surprising strength. “Have I got a story for you!” Who had time for stories? It was insanely busy and who should know that better than Louise herself who was in charge of the
ICU
that day? We
were short six nurses, and patients were being admitted and transferred out all day. I assumed she would tell me the story later, if we managed to get a coffee break.

“I’ve got to tell you now,” she insisted, pencilling a name in the staffing book and then setting it aside.

I motioned to someone to cover for me, that I’d be back to my room in a minute or two, and leaned over the counter with my elbows resting on the ledge. Louise’s eyes locked with mine and held fast.

“You’ll want to get this down,” she said, her eyes sparkling. She could hardly contain herself.

I reached over the countertop to grab a few scraps of paper that our ward clerk leaves for us to record lab results and telephone numbers. “Shoot,” I said, my pen poised. As she began to speak, it grew quiet around us. Tracy took over Louise’s work for her. Other nurses moved closer to listen and others moved out of the way as if to clear a path for this story to be told.

“Has it ever happened to you, Tilda, that you love a friend’s mother like your own?”

“Yes.” I thought about Bunny, Joy’s mother, and other borrowed mothers, both past and present. I felt a swell of all the mother love they had offered me and all that I felt for them.

“You remember I told you about Alice? She’s my best friend Meredith’s mother. I loved her like my own mother. Last year she was diagnosed with lung cancer and I made a promise to her that I would help her when the time came.” I nodded. “Oh, I wish you had known her! She was brilliant and very strong-minded. She read everything – you’d have loved her, Tilda. But during her last year, she struggled to breathe and couldn’t get around. She had no appetite and lost forty pounds. One day she told me all she wanted was a cigarette, just one. She already had lung cancer, so why couldn’t she have one? She enjoyed it so much. She had a right to that bit of enjoyment, don’t you think?” We nodded and Louise took a deep breath and closed her eyes to help her find her place in the story again. “A few days ago, Meredith called me. Her mother was in distress and they took her to the hospital. Alice said,
‘It’s time. I want Louise here. She’ll know what to do.’ I said to Meredith on the phone, ‘Just don’t let them start feeding her. And no intubation.’ Then I got in my car and booted it up there. I was going so fast, the police stopped me but when I explained why they let me go. Alice was so relieved to see me. ‘Can we do this?’ she asked, and I told her, yes. Of course by that time she had a feeding tube in place and the crash cart right by her bed. Oh, it drives me crazy, Tilda! Not every person needs
CPR
before they die!”

I nodded and reached over for a few more of those little slips of paper to get all of this down.

“Well, Alice was very anxious and having difficulty breathing. She was on a self-controlled pain medication pump, but I think she was too stressed to use it, so the first thing I did was push the pump for her and then I asked to have the dose increased. Soon, she drifted off to sleep. A doctor came in and asked why she was so out of it. He said they were taking her for a
CT
scan and then a pleural tap to drain the fluid in her lungs, but Alice had already told them she didn’t want any more procedures or interventions. ‘Who’s the one with some medical background?’ the doctor growled. He must have sensed a threat. I waved my hand to show I was the guilty party. ‘I’m an
ICU
nurse, for twenty years.’ He asked if Alice was still smoking. Alice heard that and pulled off her oxygen mask to ask me, ‘Do you think it would have made a difference if I had stopped smoking?’ I told her, ‘Why take this with you? You loved smoking. You had a wonderful life. Let it go.’” Louise rolled her eyes. “I arranged to have Alice transferred to a palliative care unit. Oh, it was beautiful there and we could all be with her. Alice asked me to make it happen faster. I would never do that, but I had to find the balance between keeping her comfortable and not speeding up her dying.”

“Louise, phone’s for you,” the ward clerk interrupted. “It’s the
OR
. The patient is coming out in twenty minutes. Will the bed be ready?”

She nodded. We all knew she’d be returning to her efficient, responsible self in a couple of moments, but there were still a few details she had to tell. “Alice looked at me and gave me that stare. You’ve seen it, right?”