You are on page 1of 13

Chapter 10

Savi ng Mr . Huzj ak
rrru tell a story. 1hey are the calloused hands o a
steelworker. 1he rest o seventy- eight- year- old Ired Hu.;ak is in no condi-
tion to engage in storytelling. I would never learn whether he even knew
we had met. Its October J86, and I am a second- year resident in medi-
cine assigned to Hanna House ! at the University Hospitals o Cleveland.
Mr. Hu.;ak lies in ront o me, obtunded, mentally dulled, eyes open,
not responsive to questions. I am not sure how conscious he is. 1he guys at
the FR who nrst evaluated him determined that he reacts to pain, but
thats about it.
Mr. Hu.;ak was brought to the FR or ailure to thrive, which is
another way o saying that he doesnt seem to have any idea o whats
going on around him. His daughter brings him in because the amily had
reali.ed that he had slowly grown unresponsive. 1his is not unusual. A
sick person oten does not talk or sociali.e much, and sometimes it takes
the amily a little while to reali.e that the amiliar quietness has changed
to unresponsiveness.
I look at the charts and see that Mr. Hu.;ak has a plethora o underly-
ing problems, including a nve- month history o Stage I\ non- small- cell
lung cancer (NSCLC). He was a pack-a-day smoker or orty years and
has been treated or chronic obstructive pulmonary disease or the past six
1he cancer had spread to both lungs, and to his spine, pelvis, and
liver. He was treated with cisplatin and \P- J6 or our cycles over twelve
Saving Mr. Huzjak
weeks. (In J86, that was the standard o care, the best we could do.)
1he disease progressed while on therapy and treatment was stopped.
Irom that point on, the goal was to manage the symptoms.
Hu.;aks dry skin indicates that he is dehydrated. 1hats because he is
too out o it to know that he needs to drink. We cant tell how much o his
brain unction is still intact. We dont know whether he is able to see or
smell or taste or hear. When we ask him to ollow a nnger with his eyes, he
doesnt. He remains inert when we ask, Mr. Hu.;ak, can you hear me
His ace is completely placid. Is this because he has no control over acial
muscles Maybe.
His extraocular muscles appear intact, though. His pupils are equal
and reactive to light and accommodation. His neck is supple. His lungs
have some breath sounds. He has bilateral pleural eusions,
nuid in the chest cavity. 1his is common in lung cancer and prevents the
lung rom ully expanding. He seems to respond only to noxious stimuli
(medicalese or pain we cause in examination). Labs show that his white
blood count is J0.! with a slight let shit. 1his is doctor- speak or evidence
o inection.
1he systems in Hu.;aks body are ailing in a relentless, rapid cascade.
i a big university hospital, you have patients who have private attending
physicians and patients on the ser vice. Patients who are on the ser vice
dont have a regular doctor. 1hey are almost always admitted through the
FR and usually are poor and under- or uninsured. 1hey get care rom
the residents, with some input rom an attending designated by the medi-
cine department or the month. At CWRU, we take pride in giving these
olks extraordinary care. Hu.;ak has a private physician, Jim Claren, a
good guy, whom we residents like.
We enter Hu.;aks room and introduce ourselves to the patient even
though we know he cant respond. You always work to show respect to the
patient. In the case o Hu.;ak, introducing ourselves may not help the
patient, but it helps the amily, or so you hope. We introduce ourselves to
the patients daughter, too.
I go through my usual introduction.
1hat day I have a team o two interns, Beth and 1ony.
How We Do Harm
We ask Hu.;aks daughter what occurred over the past week. She
connrms the history: lung cancer that grew through chemotherapy, then,
recently, social withdrawal.
We examine Hu.;ak and veriy what we have been told by our col-
leagues in the FR and by his daughter. When we nnish gathering all the
data, its :!0 a.m. I suggest to the interns that we wait till 6:00 a.m. to call
Claren, Hu.;aks private physician. Fven though we didnt get any sleep,
its better not to wake an attending or a nonemergency, especially i he is a
decent attending who doesnt abuse us. At 6:J, we page Claren and he
calls back almost immediately.
Beth presents the patient as I listen in on a second phone. Claren re-
members the history, a sign o a good doc.
What do you suggest Claren says.
Beth notes that we had started Hu.;ak on three antibiotics. 1he goal is
to drain the eusion. We are hydrating him by I\ and watching or nuid
overload. Claren agrees.
We cant do a thing about the root cause o Mr. Hu.;aks problems:
the galloping lung cancer. 1his man is near death, and we have to accept
that we are helpless to stop it. Allowing him to exit with dignity would
be the only responsible, the only humane, thing to do.
Claren says he had repeatedly tried to get a DNRa do not resus-
citate orderrom the daughter. He tried at every once visit and every
hospital admission ater it became clear that the drugs werent doing
any good. Forts along these lines are called hanging out black crepe
they are to lower expectations, prepare the amily or bad news. Alas,
Hu.;aks daughter is determined to hang on to hope.
In part, this is about our culture. As Americans, we are a never- give- up,
pull- yoursel- up- by- your- bootstraps kind o people. 1o us, death is a ailure
o medicine. Death has to be somebodys ault, and we are generous in as-
signing the blame. 1his ideology is unair to patients who, as we say, ail
therapies. And its unair to doctors, who all short o producing miraculous
cures. Unable to accept the inevitability o death, we cant make plans, cant
talk reasonably about our preerences or the circumstances o our passing
and about what we want to happen ater we are gone.
I wonder whether the Hu.;ak amilys denial o reality is in part
6 Saving Mr. Huzjak
caused by their reaction to Claren. He is patrician, a person rom a planet
dierent rom theirs. His country- club sport coats, his bow ties, his penny
loaers with dimes in place o pennies, are images the Hu.;aks may nnd
intimidating. He is a good, compassionate doc, but maybe his message is
coming through as, or simply hard to relate to.
Might class be larger than race or the Hu.;aks Would the dincult
message be heard i it came rom a young black man who came up the
hard way, who aced the same hardships they ace every day Its worth
a try.
Would you allow me to talk with her I ask Claren. (You dont med-
dle with a privates patient without his permission.)
Be my guest, he says. Just remember, the daughter has unreason-
able expectations. He tells us that she was upset when Claren declined
to give urther chemotherapy, and she said no to hospice care.
Clarens situation would have been easier had she simply nred him.
He would have been o the hook. Yet she did nothing o the sort. She let
the doctor stay on the case, but re;ected his recommendations. She did
not even get a second opinion.
When I arrive at Hu.;aks room, his daughter is in a chair, asleep. I
gently awaken her. She is in her orties, obviously tired, obviously dis-
tressed. I tell her that I know that this is a dincult time or her. I tell her
Mr. Hu.;ak reminds me a lot o my ather. I tell her that I have had to deal
with my athers illness, which was similar to Hu.;aks. My ather, too,
was a World War II vet, and he, too, had NSCLC and had a rough course
with it.
I tell her that Hu.;ak is stable or now, but his condition will change
over the next ew days, and some decisions should be made.
I would like you to talk with my brothers, she says.
1here is hope.
We agree to meet at 8:!0 a.m., and I arrange or her to have a phone
and some privacy.
. 8:!0 a.m. I enter Hu.;aks room and meet his two sons. 1hey are in
their orties. Also, I meet the wie o a son and the husband o the daugh-
ter, and one grandson. Something tells me that the sons, like their ather,
How We Do Harm
work in the steel mills. I had recently watched the movie Deer Hunter,
which was set in part among Slavic steelworkers rom a rust- belt town. I
asked one o the nurses. Hu.;ak is a Croatian name.
I explain that we are working with Claren, that he will be in later in
the day, and that he asked me to talk with the amily. I explain the ex-
tent o Hu.;aks lung cancer. Its in the liver, both lungs, the mediasti-
num (the chest between the lungs), pelvis, ribs, and spinal bones. We are
concerned that it has spread to his brain (wed need to do studies to nnd
out or sure). He has already received the best chemotherapy we have,
and the disease grew despite it. 1he cancer is progressing, and nothing
can be done to halt it.
1he disease has caused complications, which include pleural eusion,
nuid in the chest, which keeps the lungs rom expanding. We are con-
cerned about pericardial eusion, nuid around the heart, which can neg-
atively aect the pumping action o the heart muscle. His lungs are not
unctioning well. He may have pneumonia, which may be due to an ob-
struction in his bronchial tree, the windpipes. I explain that when cancer
narrows the windpipes, we oten see an inection. Pneumonia is re-
quently the immediate cause o death.
We need to decide what is reasonable, I say. We need in what ever
we do to stress comort or Mr. Hu.;ak.
I speak slowly, deliberately. I know that every poorly chosen word can
and will work against me. Ater long hours o running rom one task to
another, I have to change speeds, I have to slow down, I have to demon-
strate compassion, express it as clearly as I can. I have to understand
where they are coming rom and get to the undamental cause o their
re sis tance to accepting death as a nnal destination or a sick man. Death
in this case is not a ailure o the system.
I know how much is riding on this conversation. I it goes well, this
amily will bid arewell to Hu.;ak. I it goes badly, this man will suer
through a plethora o procedures that can only do harm.
I lay out the multiple- choice problem beore us. We must pick one o
three possible options.
I start with the most absurd: We perorm diagnostic studies and treat all
o these problems. 1his will cause their ather and grandather a lot o
8 Saving Mr. Huzjak
discomort at best, agony at worst. We will not be able to control the pain
with anaesthesia. I explain that Hu.;aks respiratory system is ragile. Drugs
that control pain also decrease the respiratory drive in his brain. Narcotics
that control the pain also bring closer the day when he will be put on a
ventilator, and once he is on it, there he will stay until his last breath.
I go through the list o invasive procedures that are in store or Hu.-
;ak: a scope placed through his mouth and on into his lungs to look or
pneumonia and obstruction, tubes placed into his chest, spinal taps, and
possibly even medicines in;ected into his chest and spine. 1hese may
prolong his lie brieny.
May is the key word. Since we cant assess him neurologically, I cant
say how ar gone he is. I dont even know whether he is conscious. Has
his cerebrum stopped unctioning Is he driven only by his brain stem
I know that he screams rom pain, but I have no idea whether this is a
primal response or evidence o more complex brain pro cessing.
Without question, we will increase his suering, but the result will not
change. He will have widely metastatic, untreatable cancer rom which he
will die.
1he second approach which the medical team and Claren avor is
to treat the pneumonia with antibiotics and watch his hydration.
I he improves, we can do a ew more things with the idea o making
him more comortable. We can drain the nuid rom his lungs through a
small catheter, rather than through a chest tube, which is a thumb- si.e
tube placed between the ribs that can be uncomortable. We would still
pay par tic u lar attention to his comort level, and i these smaller inter-
ventions caused him pain, we would give him morphine as needed.
I he were to stop breathing or i his heart were to stop beating, we
would not resuscitate him. Resuscitation involves pumping on the chest
and inserting a breathing tube in his mouth down into his lungs to pump
oxygen in and out. It can also involve shocking him to try to restart his
heart. We would instead let him go peaceully.
1he third option is to give him pain medicine now and let nature
takes its course. When he dies, we would not try to bring him back.
Since we are unable to ask Mr. Hu.;ak himsel, we have to look to
the amily to decide what he would want in this situation.
How We Do Harm
Do you have any questions
1he amily is silent.
I throw out another question. Is there anyone else that you would like
me to talk to
I have nnished talking. 1he truth is on the table. Have my arguments
pierced the wall o grie and denial
Will the older sister break the silence, or will she deer to the brothers
I wait. I watch.
1he older brother looks up rom the noor and stares into my eyes
directly, like a cop. Whats his condition he asks.
I am startled. Does he want a classincation: grave, critical, stable, a
one- word descriptor o the sort you see in a newspaper
I reali.e Ive ucked up. My pre sen ta tion was too long and detailed.
1he basic inormation was lost and the larger questions missed.
What about nutrition asks the younger brother even more aggres-
What about it I am taken aback by his tone. However, the man asked a
question and he deserves an answer. Calmly, in a nonconrontational way,
I explain that we are concerned about nutrition, but the issues in order o
urgency are his respiratory status and shortness o breath, his pneumonia,
which can impair his respiratory status and his cardiovascular status.
I explain that his albumin, a marker o nutrition, is low. 1his is common
in lung- cancer patients, but it isnt so low as to say that death rom starva-
tion is imminent, whereas death rom these other problems is imminent.
So much or my hope o getting through to the Hu.;aks. I am tired. I
sense distrust not unlike the kind we had or doctors when I was growing
up in black Detroit. I remind mysel that in my state o mind I have no
right to ;ump to conclusions. I havent slept all night. My ;udgment may be
intact, but my instincts are dulled. What should I have done dierently
Should I explain the word imminent I ask mysel. Is it too long Am I
being a tired asshole I bite my tongue. Maybe this black doctor is resort-
ing to classism to counteract racism, real or perceived. None o this is good.
1he younger Hu.;aks ask why their ather is on a nasal cannula and not
an oxygen mask. I explain that he has a kind o breathing problem called
carbon dioxide retention that can be made worse i he is put on too much
.c Saving Mr. Huzjak
oxygen. His lungs are in such bad shape that he cannot get all the carbon
dioxide out o his body, so his brain has become accustomed to high levels
in his blood. 1he only reason he breathes is the brain stems desire to get
oxygen into his blood.
1he wie o one o the brothers asks where I went to medical school.
I recogni.e the question or what it is, a passive- aggressive way to avoid
dealing with the problem.
I answer that I went to college and medical school at the University o
Chicago. I let her know that others agree with me on what we are up
against: a murderous disease that we cant slow down, let alone stop. We
may be able to prolong Hu.;aks misery, but at a cost o causing great
pain. Claren has reviewed all the data, as have the doctors in the FR, as
have the doctors on my team, there is universal agreement.
I have given them careully reasoned, compassionate inormation and
now list the white people who agree with me. 1he situation is absurd,
and I know it in real time.
I wonder whether she knows that the University o Chicago is a good
school. Nineteen eighty- six is ;ust a ew years ater the Bakke decision,
and talk o anrmative action is still ubiquitous in the news media.
While its tempting to ascribe the younger Hu.;aks distrust exclusively
to racism, it may not be accurate.
I know that even when my white colleagues try to impress on the
amilies o patients that the time has come to say good- bye, they run into
re sis tance.
One brother asks what resuscitation is like i his heart stops, or i he
stops breathing. 1his is an appropriate question, perhaps even an oppor-
tunity to build understanding.
I describe resuscitation. I mention breathing or the patient with an
Ambu bag and placing a tube down the throat into the lungs. I explain
that a patient on a ventilator, with a tube in his throat, eels as i he is
drowning, except that eeling goes on and on. I talk about chest com-
pressions to get blood nowing i the heart stops. I describe electric shock.
Resuscitation is something I do well, maybe even get a thrill rom.
But I always got a nauseous eeling ater a successul resuscitation. It is
appropriate or a healthy person who has one problem causing the arrest.
How We Do Harm .
I you restart the heart or restart the breathing, you buy time, nx the
underlying problem, and the person ends up returning to lie, perhaps
even normal lie. Unortunately, in internal medicine, we do lots o re-
suscitations on patients who are destined to need it again in a ew days
and will continue needing it until they arrest and will not come back or
until someone has an attack o common sense and says, Fnough
Hu.;aks daughter begins to talk, saying that she speaks or her
brothers. Its now obvious that she plays this role oten. She wants every-
thing done to save her athers lie.
Fverything reasonable or everything possible I ask. I tell her that
we eel that resuscitation is not reasonable in the event o cardiac or pul-
monary arrest.
Fverything possible is everything reasonable, as ar as we are con-
cerned, she says.
.s I walk to the residents once, I eel sick to my stomach. I think about
the younger Hu.;aks. 1hey will not eel the excruciating physical tor-
ture that being pulled rom death will require. 1heir ather will. 1hey
will not be perorming these senseless acts o medical torture. I will.
1hey will not be paying the bills. People paying higher health insurance
rates will.
Fconomists have a name or this: a moral ha.ard. A moral ha.ard oc-
curs when a person making a decision is protected rom its consequences.
Soon ater meeting the Hu.;aks, I sit down and, ;ust or the hell o it,
calculate how much useless, harmul care or this man could cost the
system. I get to 3!0,000 ;ust or the care we had provided and the care
we are about to provide.
1he number seems horriying.
I am in the beginning o my career, and I believe that at some point
problems o cost o care and elimination o useless, unscientinc care would
be solved either through controls by insurance companies or by the govern-
ment declining to pay.
My prediction is wrong.
Now, three de cades later, as I sit down with a pad o paper and start
adding up expenses or a hypothetical patient similar to Hu.;ak, I reali.e
.. Saving Mr. Huzjak
that today he would probably receive a great deal more chemotherapy,
perhaps well beyond the point where lie extension or even delay in pro-
gression o disease are a possibility. 1he willingness o insurance compa-
nies to pay, and the willingness o private physicians to make a buck, have
extended the standards o care enormously rom three de cades ago.
In addition, had he been brought into an FR in !0JJ, Hu.;ak would
have been sub;ected to even greater abuse and an even larger number o
obscenely expensive and ridiculous medical tests and procedures. 1here
would dennitely be more imaging a magnetic- resonance- imaging study
would be ordered to assess his brain damage. 1here would be C1s, lots o
them. A C1 in J86 was a big deal. A patient stayed in the machine or
more than an hour. Now, the rate- limiting step is how quickly your order-
lies can get patients on and o the table. I can easily see the bill or a patient
like Hu.;ak adding up to 3600,000.
No one seems to argue with the estimate that about !! percent o
Medicare spending and about J percent o all health spending is in-
curred in the last year o a patients lie.
Why such a high proportion Yes, a person whose body is ailing is
going to need a lot o medical care. Yet neecing the system is in these
numbers, too.
I have seen doctors do some horrible, irrational things under the
guise o seeking to benent patients. I have seen my colleagues disregard
data in ways that ultimately benent them nnancially: a bone marrow
transplant or a breast- cancer patient, prophylactic doses o Aranesp and
Procrit these are only a ew examples. 1he system rewards us or selling
our goods and ser vices, and we play the game.
However, I cant think o a single anecdote o doctors creating or en-
couraging situations where a patient who is ready to die is instead sub-
;ected to aggressive care. Fven the greediest o doctors rerain rom such
behavior because they know that its wrong. Its so wrong that you cant
possibly ;ustiy it. Yet, patients demand this kind o care, and we oblige.
Americans dont understand death. We cannot accept that death will
come, and thus we cannot make a plan, talk reasonably about it, work our
way to understanding, to the basic part o our humanity. 1his attitude a
How We Do Harm .
combination o perpetual optimism, reusing the dark, and not living in
reality is unair to patients, doctors, and insurance companies.
.rrr receiving my marching orders rom the younger Hu.;aks, I search
or explanations. Perhaps I care about Mr. Hu.;ak more than his nesh and
blood. Perhaps they dont want to ace other relatives who might blame
them or having let old Hu.;ak die. Perhaps they dont understand the
reality o their athers uture. Perhaps they are unable to accept it. Perhaps
I ucked up. Perhaps its pigmentation. Perhaps its class. My sel- nagellation
sets the stage or the torture I will have to innict: this man will arrest and
we will try to bring him back. He will experience the sensation o drown-
ing as we intubate him and try to breathe or him. He will have pain and
discomort that I will not be able to control. No, lets call things by their
proper name: he will have pain and discomort, and I will exacerbate this
with the pain and discomort o utile treatment.
We arent really trying to benent Hu.;ak, we know we cant. Instead
we do harm, because we are instructed to do so.
I tell the intern that Hu.;ak is a ull code, that I ailed to get a DNR
or any limits on his care. I he has a cardiac or respiratory arrest, we
are obligated to perorm liesaving mea sures. What ever it takes. We have
to our- plus him, I say. Its the equivalent o saying JJ0 percent. We have to
really try to resuscitate the guy, not ;ust go through the motions. We have
to be sincere in our eorts as we suspend disbelie.
As the internal- medicine doctor in charge, I am responsible or or ga-
ni. ing the various consulting specialist teams and their access to the
patient or treatment. In this case I am orchestrating a macabre dance,
pretending to be saving a lie that cannot be saved. 1he dance is grandi-
ose. I tell the intern to call or a cardiac consult. Ask or an echo to see
whether Hu.;ak has nuid around the heart. Call pulmonary and get a
bronchoscopy a scope will be threaded through Hu.;aks nose or mouth
and down into the lungs to look at the bronchial tubes. Pulmonary will
look or obstructions and run cultures to determine what bug might be
causing pneumonia.
Call thoracic surgery, too. We may need a pericardial window rom
. Saving Mr. Huzjak
the pericardial space to the peritoneal cavity. 1he goal would be to let the
pericardial eusion drain rom the space surrounding the heart where
its interering with heart unction into the abdomen.
We will dennitely need to insert a chest tube and perorm a procedure
called sclerosis. We will place an irritating material talcin the pleural
space to cause innammation o the membranes. Innammation will cause
the membranes to stick together, thereby eliminating the pleural space
in which nuids could accumulate.
I hope to God we dont have to perorm a lung biopsy to see whether
Hu.;ak has lymphangitic spread o his cancer, i the cancer has gotten
into the tissue where air is transerred. I the answer is anrmative, this
will only add another untreatable condition to the roster o untreatable,
atal conditions on this patients chart.
Iirst thing, get a C1 o his head with and without contrast, i possible,
but we have to get one without to clear his head or a lumbar puncture.
(Clear his head was our language or making sure it was sae to do the
lumbar puncture without danger o causing the patients brainstem to
herniate, which means to be sucked down the spine.) Ior an LP, well
tap into his spine to collect a sample o cerebrospinal nuid or microbio-
logical and cytological analysis.
An intern asks whether instead o the C1 we want to do an eye exam
to clear him or the LP. I say no, we will wait or the C1, even i that
delays his workup a day or two. In the old days, residents were trained to
look into the back o the eye with a unduscope, to look or evidence o
intracranial pressure beore the LP. We were taught to do that in case we
had to do an emergent LP and could not get the patient to the C1
quickly. But an eye exam isnt as accurate.
I you do an LP on a patient who has a tumor blocking the third ven-
tricle o the brain, you can cause herniation o the brain. 1he brain swells
and is orced down the top o the spinal canal. When this happens, the
patient goes rigid, takes some deep breaths, and dies. In medicine, there
are only a ew sudden deaths, and this is one o them.
I could do it, I was good at it, but I was not going to attempt it with this
patient. It wasnt worth the personal risk o being wrong. Hu.;ak is going
to die, and i he dies during or ater the LP, it will be attributed to the LP.
How We Do Harm .
I dont want to be blamed or a death that is coming with or without the
I push the intern to get these tests in quickly so she can get to her other
patients, put them to bed, and get home to get some rest. Hu.;ak is one o
about thirty patients or whom I am responsible. (As a resident, I am su-
pervising two interns, each o whom has to take care o six to seventeen
patients.) Hu.;ak is sucking up time, which means less attention to go
around. As a result, hospital stays are prolonged. Patients can get sick
rom bugs they pick up in hospitals. 1hey have to be treated, and some do
poorly. 1hese, too, are costs, and they have to be counted.
A patients wie is pissed. We didnt answer all her questions about
her husbands condition. She looks like a person who is used to getting
her way, and in this case her sense o entitlement is ;ustined.
Also, some poor guy didnt get the ull attention his pain deserves,
again because we were busy with Hu.;ak, the patient who cannot ben-
ent rom our care.
I pray or my patients, and that morning I pray that Hu.;ak is not
really aware o what we are about to do to him.