Across The Red Line: Stories From The Surgical Life

7. Helping Sal—Knowing When to Quit

7 Helping Sal— Knowing When to Quit One of the hardest things I know is when to give up. Knowing when to give up on hopeless projects is the province of the truly gifted practitioner of any craft. There is a little poem or prayer that asks the Lord for the strength to know what can be changed, the serenity to accept what can’t and the wisdom to tell the two apart. In surgery it is the same thing. There are decisions about which natural biological horrors to take on, about whether a tumor is resectable, about the patient’s ability to withstand a big operation and her enthusiasm for it. I’ve gotten a lot better about these judgments, but sometimes I still miscalculate. There are times when I can’t get the tumor out or the patient has a bad complication. Because things usually go well, these lapses in perfect result feel like a slap to my face and to my pride of craftsmanship. The patient, of course, does not care about how good my success rate is, she does not care about my professional pride; she cares about what happens to her. What happens is not always good. When things don’t work out like we expect and a patient whom I think I can help is made worse by my efforts, it’s a painful predicament, for I want to set things straight, make things better, start over again. Because it feels to me that I have caused the problem, I don’t want to stop trying. I’m not talking about malpractice here, I’m talking about those 65 times when experience and carefulness and good intentions are impotent. Once the patient and I have unknowingly taken on a losing cause, the dilemma becomes when to quit the fight. In time I have learned that it takes more guts to stop treating a patient when the prognosis shifts from grave to hopeless than to carry on doing what I know how to do. It is that subtle shift that is the secret. Patients don’t declare themselves irretrievable, they just drift from salvageable to dying. I keep hoping things will get better, keep looking for treatable complications to fix. Then one day I walk into the intensive care unit and I just know it’s over. In hindsight, patient’s families are often angry that so much care was given before the end, but at the time, they usually push for more treatment. My consultant colleagues also want to keep on; they see only their part of the picture, the kidney infection, the heart arrhythmia. They don’t step back and see that they are trying to fix the clutch on a car that has no engine. Only the wiser, older nurses approve when I start to prepare the family and patient as best I can for the end I see as ultimately inevitable, when even they, the patient and family, can’t see the futility of further treatment . I have been here before and I know the territory better than they do and it is my responsibility to help them make out the shapes in the landscape that tell us all that the patient will die. It is just a question of how long and after how much treatment, or harassment, the end will come. This is not a skill you learn, then know surely for the rest of your career. It is always different and it is always hard. Sometimes the most important contribution I can make to someone’s life is to help her see that it is over. I have never “assisted suicide,” but I have helped patients disentangle themselves from the well-meaning but misguided machinery of medicine. And then they die. 66 Chapter Seven Sal was insouciant from the start. She was in her early forties, but she had a tired look to her. She came over from a distant city, self-referred. She had no money or insurance , so it took a day or two of wrangling with the hospital to get her a bed. Sal worked as a waitress at a waterfront bar. She had a beautiful face, even though her skin was a sickly yellow-orange. She had become jaundiced a week ago. She didn’t notice that the whites of her eyes had turned yellow, but the bartender did. Doctors in her...