JOURNAL OF PALLIATIVE MEDICINE
Volume 16, Number 10, 2013
ª Mary Ann Liebert, Inc.
DOI: 10.1089/jpm.2013.0060
Paradox of Hope
Justine V. Cohen, DO
E dith Shostovinich* was an 86-year-old pianist. As a
young woman she played in the finest concert halls in the
world, her name renowned for her soaring solos. As she aged,
Mrs. Shostovinich grew ill and travel became difficult. She
settled into the life of a teacher at a conservatory: giving pri-
vate lessons, holding master classes, and welcoming students
and faculty to her traditional tea parties.
At the same time Mrs. Shostovinich was coping with
myelodysplastic syndrome (MDS), receiving routine blood
transfusions. She’d been diagnosed with MDS 15 years earlier
and had failed two chemotherapeutic regimens with lenali-
domide and decitabine, leaving her dependent upon trans-
fusions of blood and/or platelets on a nearly weekly basis.
Regular testing and a battery of doctor’s appointments had
become a part of her life. At baseline, Mrs. Shostovinich lived
at a hemoglobin of 6 g/dL and a platelet count of 15 · 109/L.
I met Mrs. Shostovinich on a bitterly cold December
morning when she developed a fever during one of her many
transfusions. From the day-stay unit she was sent directly to
the emergency room (ER), where it was noted she had a he-
moglobin of 5.6 g/L, WBC 25,000 · 109/L, and a platelet count
of 4 · 109/L. I was an intern at the time and I was called to
admit the patient. The ER doctor who passed me her case was
vague: ‘‘This is an old lady with MDS and fever, source un-
clear. She needs admission and transfusions.lots of ‘em.’’
I drew back the curtain in the ER and saw a short, plump
lady with her gray hair tightly pulled back into an elegant
bun, wearing sunglasses. ‘‘Do I know you?’’ she asked me. I
racked my brain—worried that I had treated her before but
didn’t remember. ‘‘I don’t think so, Mrs. Shostovinich.’’
‘‘It’s ShostVEENich,’’ she corrected me, sharply but
endearingly—with an instructing voice that her piano stu-
dents surely knew by heart. ‘‘And I’m certain I know you, but
how, dear?’’ Before I went to medical school I’d had a career as
an oboist. I immediately recognized her name when she
pronounced it correctly and was mortified at my ignorance. ‘‘I
don’t believe you could know me but I certainly know you.
Everyone knows you: you play the most beautiful Chopin
nocturnes in the world,’’ I said, amazed to find her here in
my ER.
We talked about music: my oboe and her piano. She was
still convinced that she knew me, which I was sure had to be
impossible given her fame. I did a thorough history and
physical, placed orders, and discussed her treatment plan
with both my resident and her hematologist—neither of
Department of Internal Medicine, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, Pennsylvania.
*Name has been changed.
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whom recognized that their patient was a legend in the world
of classical music. I admitted her to the special care unit where
she was to receive two units of packed red blood cells and
three six-packs of platelets along with broad-spectrum anti-
biotics and other supportive measures.
I began to look forward to my daily visits with Mrs.
Shostovinich. After I’d sign out I would turn off my pager and
steal away to her room to hear her recount memories of her
storied career, dazzling audiences across the globe. As our
bond grew I asked her about advance directives. ‘‘I have a
living will,’’ she told me. ‘‘It says that I want everything done.
And that’s what I’m sticking to so please do everything.’’ There
was no hesitation or faltering in her voice. No fear: only pure
stoicism. I documented her wishes in the chart and did as she
asked. As I left her room each day we developed our own little
routine. I would squeeze her hand and wait for her to squeeze
back in return. Then, at the door I’d look back over my
shoulder at her—with her tight bun and stylish sunglasses
that she wore even though she had not been outside in days—
and she would blow me a kiss.
But Mrs. Shostovinich’s counts continued to drop despite
daily transfusions. Our threshold to transfuse became lower
and lower. Her infection had seeded from a sore, deep in her
left nostril, which subsequently spread rapidly through her
sinuses and into her eyes. Her face became diffusely ery-
thematous and edematous with green purulent exudate con-
tinuously oozing from the medial epicanthi. This irritated her
because it hindered her vision and kept her from seeing what
was happening around her. Every so often I would delicately
broach the subject of code status, explaining to her the gravity
of her condition and offering alternatives to aggressive re-
suscitation that she might not survive. She always refused to
have the conversation, stating emphatically that she did not
want to be a Do Not Resuscitate (DNR) status, but rather a Do
Everything status. ‘‘I know you want me to know that I’m
dying,’’ she scoffed at me once. ‘‘But I’m not ready.’’ I ex-
plained to her my rationale of not wanting her to suffer. Pal-
liative care, I told her, is focused on providing comfort and
relief and could complement her treatment of MDS and pro-
long living for her, rather than prolong dying. ‘‘I don’t want
it,’’ she would say. ‘‘I want the Do Everything option.’’ She still
blew me a little kiss on my way out, but I worried that she
would resent me for bringing up such a sensitive subject.
Soon Mrs. Shostovinich developed bacteremia, likely
seeding from her nose. We broadened her antibiotic coverage,
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fearing orbital cellulitis and impending septic shock. Each day
she grew weaker and each night I was more anxious about
leaving her in my colleagues’ care, knowing that she could
rapidly deteriorate and require a barbaric code.
Finally one day she agreed to a DNR order, with continued
treatment of her disease but no cardiopulmonary resuscita-
tion, defibrillation, or intubation. I gave her my traditional
ever-so-slightly prolonged hand squeeze that night and as-
sured her softly that I would add the appropriate documen-
tation to her chart and relay her new code status to the
covering night house staff. She barely squeezed back, but to
my relief, blew me a kiss at the door.
I left the hospital that night feeling unburdened. This was
the right decision for this patient who had become such a large
part of my life. I never wanted to pressure her or let her feel
that we were giving up on her. Having established a rela-
tionship, she trusted me. It was the first time in my life that I
felt a sense of ultimate responsibility. I slept well, knowing I
had done something to help this woman at the end of her life.
Desaturation and shortness of breath lead to a CT thorax
revealing septic emboli to her lungs. I read about MDS, noting
that most patients die of an infection, and prepared myself for
the inevitable, comforted that she might die peacefully with-
out aggressive efforts. I continued to visit her and talk to her
family about music, teaching, and the piano. She had become
too weak to say much.
One day I received a page. Mrs. Shostovinich wanted to see
me immediately. ‘‘There you are,’’ she said quietly when I
PERSONAL REFLECTION
arrived. ‘‘I’ve been thinking about it and I want to change my
code status.’’ Hospice at last, I thought. She then belted out with
as much force as her now-frail body could muster: ‘‘I want to
go back to the Do Everything status. Please reverse my DNR
order; you have given me hope and now I want to live.’’
* * *
Mrs. Shostovinich passed away peacefully five days after
that. She was a full code for two days before she finally suc-
cumbed to her doctors’ and family’s wishes for comfort. In
caring for her so deeply and devoting so much of myself to
her, I had paradoxically given her hope that she would live to
walk out of the hospital and go back to her life as a piano
teacher. It was a paradox that medical school had not pre-
pared me for. Perhaps I was Mrs. Shostovinich’s final student:
she made me question whether success in medicine is defined
by the lives you save or the quality of life you preserve.
Address correspondence to:
Justine V. Cohen, DO
Hematology and Medical Oncology
Yale Cancer Center
333 Cedar Street
PO Box 208028
New Haven, CT 06520
E-mail: Justine.cohen@yale.edu