The Road through Residency:

Hopes and Dreams

As the Greek myth goes, once Pandora had lifted the lid of the jar, every manner of evil escaped to torture and punish man. She quickly covered the jar back up, as the last evil escaped. Wondering what was left in the jar, she peered inside and found the only thing remaining was Hope.

As a metaphor, the myth shows that in the most trying times we are often reduced to the core virtues we inherit by being human. In medicine, we sometimes stand on a precipice, below which the cold, dark sea beats against the rocks. There comes a decision then, whether to carry Hope away from this cliff or allow to it drop into the rocky chasm below.

I'm standing outside the hospital room with the family as the patient's chest rises and falls easily. The ventilator beeps occasionally during the conversation, distracting the patient's adult children. Their gazes dart into the room as an alarm sounds, but it is only the blood pressure monitor, because the cuff is off the patient as the nurses clean and organize the bed. Their looks are composed of love for their dying father, confusion over all that is taking place, judgment upon the care we provide, and fear of facing their own mortality at some time in the not-too-distant future.

"But I, being poor, have only my dreams; I have spread my dreams under your feet; tread softly because you tread on my dreams."
-W.B. Yeats

I'm discussing the code status with the family. In Ohio, the law in all its ignorance and politics, has decreed the setting of three different levels of care during a cardiac arrest, although two of these levels overlap enough to render them useless. The law is yet another attempt by a rigid, arbitrary system to impose categorization, an organizational approach, as a blanket solution to a situation that is anything but homogenous. I attempt to explain the differences among a Full Code, DNRCC, and DNRCCA. They're convoluted and difficult for the family to understand, and-I have to be honest-not easy for me to grasp either. I go over what would happen in a cardiac arrest, or a respiratory arrest, and reassure them that at no time will any care be withdrawn that isn't already in play. The patient's wife, who has been looking down at the ground as I speak in such cold, technical terms, looks up at me. Her gray eyes wet, her age-worn hands folded in a prayer-like frame, she asks, "What are his chances?"

The stethoscope hangs around physicians' necks throughout the day. Over time though it often starts to feel like an albatross, worn not to remind us of the transgressions against man, God, and Earth that we have already made, but of those we have yet to commit. It warns us of the mistakes we will make, the people we will fail, the inability we have yet to face. Throughout many patient rounds, I have often seen older physicians throw out percentages, estimations, ideas of what the prognosis likely will be. What I came to realize over time is that these are really, in most cases, guesses. Yes Virginia, miracles do happen, but rarely.

So here I am, standing in front of this elderly woman, who longs for the man she has loved for greater than a half-century to get up and dance with her one last time, and the family wants me to guess what his chances are. I could say what I truly think: that he is critically ill and has very little likelihood of survival. That even under the best circumstances, in the healthiest people, cardiac arrest is 50/50. That I don't think he'll see out the night. I squeeze the stethoscope in my hand as if I could strangle the albatross I'm forced to wear. I look at the family, their eyes full of expectation.

I answer honestly: "I don't know what his chances are… but I'm hopeful." They nod and go to the bedside. The patient remains a Full Code, and, despite our interventions, overnight he passes on. Over time, the conclusion I've come to is that it is best to be honest, but not at the expense of dashing someone's hope. It is all we have, in the end, and it is not for us-or anyone else-to tread on.