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The Missouri Review 27.1 (2004) 18-27



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Living Will

Wilbur reston was already in the intensive care unit of the tiny Florida hospital when I arrived at 2:30 A.M. I had been doing a series of temp jobs after having completed my medical residency at New York City's Bellevue Hospital and now found myself in a small town on the Gulf Coast. The breathing tube in Mr. Reston's throat and his heavy sedation precluded formal introductions. But there was a typewritten summary of his medical history that his wife had left with the nurses: a two-page, single-spaced account that chronicled the rebellion and demise of each organ in this sixty-one-year-old white man. He had survived three heart attacks and seven strokes. One kidney had been removed. He suffered from diabetes, high blood pressure and congestive heart failure. He had emphysema, glaucoma, severe migraines and arthritis. His medical history included pancreatitis, diverticulitis, pyelonephritis, sinusitis, cholelithiasis, tinnitus and ankylosing spondylitis. The typed paper also mentioned gastro-esophageal reflux, vertigo and depression. I quickly glanced over to the man hooked up to the ventilator to verify that he was indeed alive.

His wife had told the ER physicians that he'd stopped taking his water pills several days ago. Eventually he could no longer breathe. He possessed a living will stating that he did not want any life-sustaining procedures. In the ER, however, he had apparently agreed to be intubated. It had taken an enormous amount of sedation to get the breathing tube in, and then his blood pressure bottomed out. He was now unconscious in the ICU on multiple pressor medications to support his blood pressure and augment his weak heart. In Bellevue terminology, he was a "train wreck."

Mr. Reston had been admitted to East General Hospital at 2:00 A.M. My colleagues in the small private practice where I was working had instructed me never to go to the hospital in the middle of the night. "Give your orders over the phone and see the patient in the morning," they advised. But I was still too new at this kind of medicine to be that confident; I had to at least lay eyes on the patient before I could decide on any medical orders.

I couldn't take a history from Mr. Reston since he was, at present, unarousable due to all the sedation. My physical exam was brief. Mainly I plowed through the typed medical summary, converting it into a concise admission note. I handed my admitting orders to the [End Page 18] nurse, and then there was nothing for me to do. In this small community hospital, the nurses were used to, and entirely comfortable with, working without any doctors around. How unlike Bellevue, where interns and residents roamed the halls twenty-four hours a day, deeply and intricately involved in the minutiae of medical care. Here, the nurses took most of the doctors' orders over the phone and did everything themselves: drew blood, inserted IVs, did EKGs, obtained blood and urine cultures, sent patients for X-rays, followed up on test results and so on. The doctors, with their busy private practices, usually visited once a day, either very early in the morning or late, after their office hours. The emphasis was on remembering to sign verbal orders within twenty-four hours. Not surprisingly, the head nurse was taken aback and almost alarmed when I showed up in the middle of the night for Mr. Reston's admission.

It was now nearly 4:00 A.M. as I drove back to the hotel in my rental car. The main roads of the town were deserted. I rolled down the windows and was quickly enveloped in humid, orange-scented fog. Stretches of flat, boring landscape were broken up periodically by strip malls. Neighborhoods of low-slung, white stucco houses were dotted with pickup trucks and palm trees. The smell of blossoms had not been fully eradicated by the burgeoning construction industry.

Southwest Florida was nothing like West Palm Beach, which I...

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