With experience comes the wisdom of knowing when to dwell on something and when to move on. It will be a long time before I have that experience or that wisdom. It has been a long time coming, but I finally had the chance today to say good-bye to my first patient: a man in a persistent vegetative state who I began to visit as a junior medical student after the onset of his loss of consciousness. Since he became my patient on my first day on the wards, I have had the joy of seeing several of my patients discharged and sent home, eager to get back to their lives. I have also seen another patient die, despite the best efforts of my team and the other doctors as they fought to preserve the fragile strings holding together his life. Caught between these two extremes is my first patient: unable to leave the hospital through either doorway.
For a student with some early interest in Critical Care, it has been an incredible eye-opening experience to participate in the care of a man who represents the perfect storm: no history, no family, and no advance directive. Here lies a man to whom I did not have the opportunity to introduce myself while he was awake and conscious, and judging from his neurological status, I never will. “The lights may be on, but no one’s home.” It brings to light questions of the nature of personhood and the human soul. What makes a person? What is the lowest common denominator – the minimum requirement, the most basic unit? What gives us a soul, and at what point does that soul depart from the body in the process of dying? From the perspective of a Neurologist and most physicians and scientists, the brain is the final common pathway: without the functional brain, there is no life. Accordingly, we examine patients for the most basic reflexes of the brainstem, the primitive brain, which also carries the patient’s pathways mediating consciousness. Without consciousness, our perception of human life falls apart: there is no response, no communication, and no bidirectional connection to another human being. Humans are, at our core, sociable creatures, and we define ourselves by our ability to relate and interact with one another. If connections cannot be made, does death ensue?
As physicians working with the dying, we dread most the desire of a family for futile care: life support treatment without any significant chance for a return to consciousness. These situations expend resources and the time and effort that might otherwise be spent on other patients, and perhaps more importantly, we wonder whether the patient would want their body perpetuated in a mechanical stasis if there is little or no chance for recovery. Therein lies the dilemma: as healers, we strive with every effort toward preserving life, and yet we sometimes find ourselves in the position of wishing a peaceful passing for dying patients in opposition to our instinct and imperative to intervene. Some people abhor our current life-preserving technologies for producing these expensive, ethically disturbing, and emotionally challenging situations, but they lack the perspective of the tragedy of the many lives lost that otherwise might be saved. How do we judge the quality of human life? Should we abstain from treating children with cancer because we know that our treatments may give them severe chronic diseases if they survive to adulthood? If we had taken this defeatist attitude with HIV/AIDS, how could we have possibly succeeded in making it possible to live a normal, mostly unfettered life span taking only a single pill a day? Our science and treatment is imperfect. Imperfection produces side effects, but we have to do the best we can with what we have until we can create something better. For now, that is why we hope patients will have advance directives, living wills, powers of attorney, or at least a clear, communicated idea of what they would wish for.
Until that day or until I face these issues as a physician, all I can do is take one minute out of the day to grasp a man’s hand and say: “I will no longer be checking in on you as one of my patients, but nevertheless, sir, it has been my honor caring for you. I hope you find your way home.”