Like a River

As I prepare for the resident seminar on End of Life Care, I carefully review my notes on advance directives. I read that some experts believe that advanced directives may have limited application in complex medical situations. As I mull over this notion, I find myself thinking about the instructive if somewhat unusual case of Mr. Kalindi. Mr. Kalindi was born eighty-five years ago, along the Euphrates River. After a full life of job sorrow, war, and displacement, he eventually became a patient of mine, having developed moderate dementia. He was a big man, with closely cropped gray hair and a sunny smile that sent deep wrinkles across his face. Whenever his family brought him in to see me, he proudly used his sparse English, repeating words for emphasis. Most of the visits ended with a firm handshake and his signature phrase, "I am very good ... very good. Thank you. Thank you. You are a very, very good doctor ... very good." One morning I arrived at the office and learned that Mr. Kalindi had been admitted to the hospital during the night with a stroke. "Brain stem," my partner said, shaking his head. "It really looks bad." I went over to the hospital and found Mr. Kalindi lying in a ward bed with his wife and two children standing close beside him. He was barely conscious and, with an oxygen mask strapped to his face, his breathing sounded like drowning. I offered my condolences to those assembled. "Did he ever say what kind of medical treatment he would have wanted in a situation like this?" I asked, knowing I should have had this conversation earlier. "For example, would he have consented to mechanical ventilation?" Mr. Kalindi's son, a critical care physician, indicated that he would be speaking for the family. "We talked about it before my father became demented," Dr. Kalindi said. "He was quite emphatic that he would never want to have a breathing tube, even for a short period." His sister nodded her assent. Their mother looked silently at her shoes, overcome with grief. I reviewed the case with my neurologist and left the hospital, not expecting Mr. Kalindi to survive the night. At least, with a no-intubation order, we would avoid a frantic and messy transfer to intensive care at three in the morning. The next day during rounds, I found Mr. Kalindi very much alive. More surprising was when he slowly turned to me and struggled to say, "Goo' morn' ... Goo' goo' morn.'" His voice sounded like he was gargling wet gravel. An urgent speech evaluation confirmed my clinical impression. Mr. Kalindi could not swallow. I called the son and gave him an update. I asked for further details about Mr. Kalindi's wishes for medical care. "Well," Dr. Kalindi informed me, "Dad said he never wanted to have artificial feeding--no tubes. He hated the idea of tubes." "Okay. What about an IV line for hydration?" "I think that's reasonable. We will support him for a few days. If he makes it, he makes it. If not, well, nature will take its course. He is old and demented and is more than my mother can handle." "I just need to be sure that that's what he would request now if he could." "Yes, I'm sure. Absolutely. We want him to be comfortable. That is the main thing. Do whatever you can to keep him comfortable." One thing that seemed reasonable to keep him comfortable was a scopolamine patch to help dry up the secretions pooling in his throat. With the son's consent, I wrote for the patch, and then went to my clinic. During the night, the scopolamine did its job--the secretions improved. But the drug also caused his bladder to obstruct and the covering physician had little choice but to put in a Foley catheter. When I found this out the next day, I cringed. The "no tubes" request had lasted less than twenty-four hours. I sheepishly informed the family members. The daughter was not upset. "It is okay, because it will make him comfortable. …