Like a dried-apple doll's, Carmela's 99-year-old wrinkled smile was sweet but a little spooky. She had come to the hospital from home, with two daughters in their 70s, her little old medical doctor of 30 years, Dr. Jones (also in his 70s), most of her teeth and one badly broken hip. They're not too impressed with high-functioning centegenarians in my hospital anymore; we get quite a few these days. But Carmela stood out. She was a little deaf and a slightly wacky but she had a twinkle about her. She was just so cute and vivacious that you couldn't help liking her. And she loved to talk — only not in English. Her hearty Neapolitan dialect went up and down like the heaving deck of a ship, straining my year of college Italian. When she realized I could make her out, though, it sealed the deal — we would, of various necessities, be friends.
It took a few days, many medicines and quite a few units of packed red cells to get her blood counts up to the point where she could have the hip operation safely. This is a dicey business with the very old. The transfusions put them into heart failure (the heart can't keep up with the fluid overload, which backs up into the lungs), which has to be treated with diuretics, which drop their pressure, which ruins their kidneys, which makes the heart failure worse. Pneumonia, bed sores, blood clots and dementia nip at them too, along with the paralyzing pain of the broken hip, almost from the minute they fall. It's dangerous to let hip fractures go too long pre-op — and somewhat inhumane. Ask anyone who has had one; the operation relieves a terrible pain. It is very gratifying as a surgeon to pin a hip. But to whisk Carmela straight off to the operating room with just six grams of hemoglobin and wet lungs, would have almost certainly killed her. So we had to wait while her medical men did their thing. And her relatives signed the DNR.
DNR means Do Not Resuscitate. It's a legal document that patients or (more often) their loved ones sign in the presence of witnesses. It says that if the patient gets into certain kinds of trouble, we're not supposed to use "extraordinary means" to help them out. Typically it means if their heart stops we can't code them and if they have trouble breathing we can't put in the endotracheal tube to keep them breathing on a machine. Implicit, it seems, in a DNR order is the idea that the patient's "quality of life" is so low that it's not worth the pain, discomfort and indignity of coding and ventilation. (Even the most pragmatic fans of DNR feel queasy about adding "and the expense" here.) Also implicit is that the emergency — usually a heart or lung problem — we're not treating because of the DNR order will quickly prove fatal.
An unfixed hip fracture is usually fatal too. But even having asked for the DNR, there was no question how Carmela's family felt about this — they wanted me to fix Mama's hip. So when she was ready, we got some more blood and brought her down to the OR. They couldn't get a spinal into her twisted, arthritic back so the anesthesiologists put her to sleep, put in the tube, put her on the breathing machine. As we worked on the hip, her ancient heart got balky. So they gave her the same drugs and used the same electrical devices they might have used in a code. And it worked. We sewed her up and taped on a bandage. Some pain meds and antibiotics, a few more units of blood, and a few days later there she was in the chair by her bed, all smiles and wrinkles again, red bandanna on her head, eating everything on her tray, babbling on in Italian about how Americans eat garbage, making me late for the office. I could already see the happy ending. How great it would be to send her off to rehab now, close the case and blast the DNR commies to hell.
Then she got sick. I could hear the rattle in her chest the next morning. Her color was off too. Three days later she was brightly jaundiced, yellow as a banana, working hard to breathe. She lay on her side, so small, swollen and miserable with belly pain. Rounds were faster with her because she couldn't say more than a few words — but far less happy. Boy did she look old.
Little old Dr. Jones was upset too: "I'm treating the pneumonia but the daughters won't let her have an ERCP. What can I do? Can you talk to the daughters? I even tried to explain it to Carmela. But I don't think she can understand."
ERCP (for endoscopic retrograde cholangiopancreatography) is a non-surgical procedure to unplug the blocked ducts around the liver. These ducts were probably backing up with infected bile, making Carmela sick. I was sure she didn't like being sick. But I was not sure Carmela understood she had been deemed incompetent to make the decision to have ERCP herself. How could anyone even try to bring up the DNR topic with her?
I caught up with the family the next night. They took me down to the other end of the hall to talk.
"You let me put her to sleep, cut her open, bang a metal nail into her bone, transfuse all that blood, and you won't let the GI doctor slip a tube down her throat with a little Valium?"
"She's been through so much," was pretty much all they had to say.
They wouldn't let her have it, so we used the antibiotic. And it worked. After another week, her color was back to normal; all signs of infection were gone. I saw old Jones in the hall and gave him our doctorly congratulations. Great save, Ken.
On rounds there she was again, sitting having breakfast, looking at the Gideons at her bedside. I had some time so we talked.
"Feeling better?"
"Yes the hip is good."
She bragged about the five steps she had taken around her room that day. But I sensed that the talk about the hip was just holding me off. Doctors are allowed to ask questions so I bored in. But my friend wouldn't discuss her belly, her color, her appetite or anything else having to do with that last, sick week. Carmela wasn't right — a good mood, ostensibly, but there was a hole in her. It bothered me, so I joked. "Well, I hope your daughters are coming in with some better food than this tonight."
Her smile crashed and she looked away.
Oh, well, no big deal. She'd spent three weeks in the hospital; had five or six major medical problems; she was an old, old lady. Lots of the usual reasons for mental status changes, even emotional lability. The medicines, the pain, the unfamiliar surroundings. Yet, almost certainly, another thing had been broken, more painful, perhaps, than her hip.
That night I got into bed, purposefully considering all the good things about Carmela's case: her chest was clear, labs normal, hip stable. We were just waiting for a rehab spot now. But the question gnawed. It's unfortunate answer arrived before morning. It was 1:53 a.m. when the night nurse called.
"Sorry to wake you, but Dr. Jones just wanted me to let you know..."
"...No, they didn't because, you know, she was so old. And she was DNR and all."
"This is a complete waste of time," I said aloud, sitting up after trying for three hours to get back to sleep. A waste of effort, of time, money and blood is how many in my medical community would have described our dealings with Carmela over those three weeks. Such pragmatic folk I doubt would have had much trouble getting back to sleep that night.
But was it the DNR that killed her? Indirectly, maybe. I think it was realizing that her daughters planned to withhold care that made her give up. When you're 99, though, doesn't something have to get you? How many years of care can a 75-year-old child give a mother? So many questions, and such huge, universal ones, revolved around that wrinkled smile. At least one of them — the ancient question about a doctor's role in this situation — came with an answer. An old teacher of mine explained it this way: "I will neither give a deadly drug nor will I make a suggestion to this effect."