Probably won't resuscitate (by Danny Chamovitz)

“By all means resuscitate! … implies a splendid life, one not always delightful, but clearly fascinating and fulfilling. A life that, given the essential ingredient of an alert mind, I would want prolonged even at the expense of broken ribs and skin burns from heroic resuscitation.” This is how my father David Chamovitz describes his choice for the title of his autobiography.

Unfortunately, as I write this, the ingredient of an alert mind no longer holds for him. As he lies in the hospital, recovering from pneumonia, his mind has escaped to conversations with his brothers Irv, Allen and Jerry, all long dead. At 88, he is suffering from dementia likely brought on my numerous mini-strokes. Over the past year his cognitive abilities have rapidly declined as he has also lost physical control of walking.

However throughout this, we have been immensely blessed as he has maintained his loving demeanor. And even now, as most of his day is spent lost in yesteryear, he has brief moments of surprising clarity, as when each of his five grandchildren visited him over the past few days. For each he managed to open his eyes, recognize, and give a loving sentence, specific for each one, only to then retreat to conversations with those no longer among us, or to admonitions to let him go home.

“To go home”. Therein lies the rub.

Is he asking to go back to his apartment, to his bed, to Marcia? Or is he asking to go home in the biblical sense? “To go home” is the idiom that my father would often use for his patients, perhaps to make death easier for their loved ones.

Indeed over the past several weeks, as his rapid decline became clear even to him, my father more than once questioned the need to keep living. The pain of his decline, and the panic it induced in him, led him to clearly tell me, about one month ago, that the joy of life, the joy of being around family, did not make his suffering worthwhile anymore. That he had come to terms with the fact that he was not going to improve, and that while he no longer felt a need to live. That daily life was too difficult.

This was the last completely coherent conversation I had with him.

So now as we contemplate our next steps, my sister Raina and I struggle with postponing the looming loss of a parent. On the other hand, my father was clear in his wish – prolong his life only if he has an alert mind. I think love for a parent mandates that we honor this wish.

Epilogue: My father passed away peacefully on January 6, 2014, with my mother and his wonderful care-taker Theodora at his side. Five days earlier we succeeded in honoring his wish and had him released from the hospital to palliative care at home. Among his final words: "likewise" in response to me telling him "I love you", "Shut up!" in response to repeated requests to open his mouth to take medicine, "Hi sweetheart", to my sister the morning before he died.

A Doctor in the Family

This chapter could be titled mea culpa or the Hebrew parallel, “al het,” asking forgiveness “for the sin ... .”   Though not sealed in any oath equivalent to that of Hippocrates, an admonition not to treat one’s own family is nearly as binding.  And yet, many times there were extenuating circumstances, which placed me in a compromising role I could not avoid.

Take for example my treating my wife, Marcia, for “the flu.”  In the fall of 1954, we were living in Boston while I began a two-year fellowship in internal medicine at Lahey Clinic. Marcia developed symptoms typical of an upper respiratory infection: low-grade fever, sore throat, coryza, and a non-productive cough.  I listened to her lungs with a stethoscope and heard no abnormal sounds.

The following day when her temperature rose and her cough became productive, I threw in the towel and called a seasoned internist-colleague.  Within a couple of hours he examined Marcia and heard moist crackles – rales – in one of her lungs.  “I believe Marcia has pneumonia, Dave.  Let’s take her to the hospital for a chest x-ray.”  And, of course, the diagnosis was confirmed; Marcia was hospitalized and quickly recovered on penicillin therapy.

It is possible that the “rales” may have developed between the time of my exam and my friend’s.  More likely, thinking wishfully, I tuned them out.  And therein lies the inescapable truism: as physician to one’s family, the doctor’s judgment is faulty.  He will go to the extremes of denial, wishing away any abnormal findings. Accordingly this relationship is to be avoided whenever possible as will be re-enforced by other examples that follow.

I was one of three internists who treated heart patients in Aliquippa.  The other two are now dead so I can freely claim that I was the most experienced and up-to-date with newly developed techniques.  It therefore seemed logical to me to be my mother’s doctor when she developed heart trouble.  The relationship worked well for several years until one day in 1971 when my mother was 84 years old.  Over the telephone I could hear that she was in severe congestive heart failure.  I called an ambulance; we arrived at Mom’s house almost simultaneously.  We sat her up in the ambulance stretcher; this gave some relief.  As soon as she was in a hospital bed, I began the then state-of-the-art therapy.  First order of treatment was to put an oxygen mask on her.  I then applied tourniquets to her legs and arms, which lowered the work of her heart by reducing the circulating blood volume (not to worry, the tourniquets were removed at set intervals so that no extremity went without circulation for too long). This should have worked.  A nurse administered an injection of morphine to try to relax my mother’s frantic breathing efforts.  I then gave an intra-muscular injection of a mercurial diuretic again to reduce the fluid, which was backed up in her lungs.  Lastly, I injected intravenous aminophylline to relieve bronchospasm.  I won’t say I was proud of myself but I was self-consciously aware of the nurses watching me take control of the situation with such dispatch.

The only problem was that nothing I did seemed to improve my mother’s dire condition.  I was at a loss for something more to do for my mother who would soon die.  A “code blue” announcement went forth over the loudspeaker system, which would bring more help.  I don’t know who was inspired to initiate the call but within minutes in rushed Dr. Horto, our Turkish anesthesiologist.  He assessed the situation in less than a minute and within another, without asking my permission, inserted a tube through my mother’s mouth into her trachea.  Immediately he began pumping oxygen under considerable pressure.  This would force fluid from the breathing spaces in her lungs into the blood stream, making room for exchange of oxygen and carbon dioxide.  Within two to three minutes my mother’s breathing was easier and much less bubbly.  Her previously blue nail beds began to pink up, indicating improved oxygenation of her tissues.  (If my mother had been fully aware, removing her meticulously applied fingernail polish to expose the underlying innate color would have angered her.)  Within five minutes of Dr. Horto’s treatment, Mom opened her eyes and smiled at me.  Because of the tube, she couldn’t talk but it was evident that she was out of trouble.  Within ten days she was fully mobile and was discharged home.

Where had I failed?  It was obvious that I couldn’t bring myself to carry out the most significant therapeutic measure on my own mother; it was just too invasive.  Mom lived reasonably active another three years until her heart failure returned, that time not to be reversed.  Within hours she was dead.  As she was dying I spoke with my brother, Jerry, a superb physician, who asked, “Are you ready to let go?”

I replied with a choked, “Yes.”  I would not have been three years earlier.

The issues are clear.  With my wife, wishful thinking blunted my diagnostic acumen.  With my mother aggressive action on my part was unthinkable, too disrespectful, too unfilial.  My role as a physician was subverted.

At least I did act appropriately, albeit harshly, when Mom at age 82 caused a traffic accident in which her car was nearly totaled; she got out of the car and, adjusting her hairpiece, asked a passerby to call her son.  It was painful for me to take the driver’s license away from my mother but I gritted my teeth and did it. (Ff turnabout is fair play, my children did this to me last month!) She was less accepting when two years later, I took control of her checkbook.

My daughter Amy was not always easy to read.  As I look back on her short life, I have to admit that I, we – Marcia and I – more than once questioned her judgment as when at age six, she shouted that a suitcase had just fallen off our car luggage rack; 100 miles later she was vindicated.  So when she rather casually claimed a broken leg from what I witnessed as a rather gentle fall while skiing, I had her sit while the rest of the family finished our ski afternoon.  To placate her when we arrived home, I took her into the x-ray room of my office and x-rayed her leg.  I couldn’t believe the result: a long spiral fracture of the tibia.  I was in no way exonerated when both the ER nurse and, subsequently, the orthopedic surgeon asked, “Which leg?”  Fortunately no harm came to Amy by the several hour delay in my making the diagnosis, not even significant pain.  Both of these incidents did give her leverage in subsequent disagreements with me.

A judgment error for which I probably will never forgive myself also concerned Amy.  It was the morning after we had retrieved her from Hampshire College in Amherst, Massachusetts.  Afflicted with manic depression, Amy had made superficial cuts on her wrists.  She called us from the infirmary to say that she felt like jumping out of a window.  Marcia was at her bedside within hours while I arrived some time later by car.  Immediately on our return home we made an appointment for the following morning with a psychiatrist in Pittsburgh, thirty miles away.  That morning Amy was acting strangely; that was the only description I could apply.  As we got into the car, she was acting somnolent and “acting” was what we thought was the explanation.  I wavered between going directly to my hospital one minute away and proceeding on to Pittsburgh, an hour away.  I elected the latter.

By the time we got to the psychiatrist, Amy was in a deep slumber.  He ordered us to proceed directly to a nearby hospital where remnants of sleeping capsules were aspirated from her stomach.  Amy lay in a coma for two days during which time I didn’t budge from her unit; I had to be there when she awoke or if further complications were to develop.  She did eventually recover; I didn’t.  It is obvious that my judgment was terribly impaired.  How could I think it was just another of Amy’s tricks?  Or was I afraid to confront the staff of my hospital  – where I was "infallible" – with the reality of my mentally sick daughter? 

The most recent incident of questionable professional conduct occurred in reference to Marcia’s resolve to donate a kidney to her niece.  The final decision regarding her acceptability and ultimately the surgery were in the hands of a team in New York.  She received instructions for arranging a preliminary battery of tests here in Israel.  In addition, forms for a complete history and physical examination were to be completed by a doctor. Marcia had no family doctor and certainly no one could document as complete a history and as expeditiously as I.  I therefore undertook the responsibility.  I assiduously performed each examination as objectively as possible. It took concerted effort to fight the desire not to find any abnormality. Certainly I could not overlook any finding that might jeopardize Marcia’s life should she undergo the nephrectomy.  The only important finding was borderline high blood pressure. I was not concerned but reported it accurately.

When the surgeon who was responsible for Marcia approached her, it was obvious that he was riled up over something. Immediately Marcia saw him as an adversary who would prevent her from saving her niece’s life.  “We never use a sixty-six-year-old donor unless it’s for her own child. And does your husband not know how unethical it was for him to do your history and physical?” Marcia listed my professional qualifications, all irrelevant.

By the time the surgeon took Marcia’s blood pressure, she was in a rage and her blood pressure proved it. “Your husband lied! Your blood pressure is not 160/80.  It’s 200/100!”

 “Do you think my husband wants me to die?  Let someone else take my blood pressure in another hour.” She was terrified of further antagonizing him, lest he disqualify her as a donor.

Well, the surgeon was not entirely wrong about my completing Marcia’s examination.  But not only did he not seek an explanation, he didn’t suggest having a colleague redo the exam.  Eventually she went through the surgery and with no untoward effects, her niece was restored to good health, and a year later the surgeon was looking for a new job.

Every once in awhile when I’m berating myself, I wander back in my mind to 1967 to our family trip to Israel.  We were at a swimming pool in Eilat when Danny, age four, cut his forehead.  The cut was about one centimeter wide but deep.  We rushed him to a local clinic where the nurse indicated that no doctor would be available for another hour.  Hearing that I was a doctor, without checking my credentials, she handed me a sterile suturing kit.  With the help of a local anesthetic I deftly applied two sutures.  I was pleased with my handy work but much more so when Danny said, “Gee, Dad, you’re a great doctor.”

If I Could Only Have A Hotdog

Clashing wills with a patient generally calls for a medical divorce.  It would be appropriate for a physician to say, “It’s time I remove myself from your care and turn you over to another doctor.”  In truth in all my years of practice this never happened.   Once it should have but the patient was my cousin’s wife, Fern.  I loved her; there was just no way I could abandon her.

Fern was only two years older than I but, having started raising a family eleven years before me, she had played a senior role in my eyes.  Our lives interlocked in many spheres.  She became one of my wife Marcia’s best friends.  Every year the two spent many hours each day for three months fine-tuning Broadway musicals that Marcia had adapted to Hadassah themes.  For years the three of us sang in the synagogue choir.  We laughed together a lot and at low points we comforted one another.

My cousin Milton, Fern’s husband, was one of the most competent public figures I had ever known.  In addition to being a superb optometrist, he was the editor of the prestigious national optometric journal and simultaneously president of our synagogue, Hopewell Jointure School Board, and the Beaver County Community College.  It was not unusual for him to have three meetings in one day and chair them all with aplomb.  I obviously admired Milt greatly, which allows me at this late date to be candid about the disagreement I will describe.  Besides, he’s no longer around to take umbrage.

Being the physician to family members is fraught with potential problems, not the least of which, because of wishful thinking, is the possibility of overlooking significant illnesses.  (I can confess to missing my own wife’s pneumonia though I had enough sense to ask a colleague to examine her; he, in turn, made the diagnosis and put her on the right tract.)

Therefore it was with some trepidation that I started my study of dear Fern when she presented with back pain.  From her story I early suspected that it was not the common garden variety of musculo-skeletal disease. Testing by means of ultrasound of her abdomen raised the possibility of a tumor of the pancreas.

With Fern and Milt’s consent, I referred her to the Presbyterian Hospital in Pittsburgh under the care of my gastroenterologist brother, Bob.  Within days a surgeon performed an abdominal exploratory operation; the diagnosis was inoperable cancer of the pancreas.  This carried a death sentence.  Occasionally radiation therapy was used but it really had little to offer.  The same was true for the early chemotherapeutic drugs.  Fern would die within a year.

Bob accompanied the surgeon to the family waiting room and nodded in agreement as the surgeon spoke to Milt.  “I’m sorry.  I have nothing to offer your wife.  No one does.”

Without a moment’s hesitation Milt took control.  “In that case, Bob, can you get me a key and show me the way to the hospital’s medical library?”

Milt spent the next four hours researching every entry related to pancreatic cancer.  Without any input from Bob or me, Milt made his decision.  He called a “scientist” doing immunological research on cancer therapy in the Bahamas.  Two weeks later he and Fern were on a plane in search of the “Holy Grail.”  At least that’s how I perceived Milt’s gesture.  Although I did not approve this turn of events – I wasn’t even certain that the scientist was legitimate – I did not fault Milt; decades later “immunological research” has become credible and is beginning to impact on patient care.  I trusted that, at least, Fern would enjoy the tropics.  

When Fern’s condition slowly deteriorated, Milt brought her home.  He thereupon embarked on a variety of therapies scorned by conventional cancer specialists but nevertheless pursued by what would now be called “alternative medicine”. Their treatment consisted of injections of worthless Laetrile, high colonic irrigations, and a very low-protein diet.  Fern went along with Milt’s frantic efforts to prevent the inevitable.  Understanding my cousin’s need to do something, not to stand idly by while his wife was dying, I reluctantly went along with these charades.  Sad to say, Milt was contemptuous of all offers for counseling that might have helped him adjust to the somber reality of Fern’s impending death.

I was appalled by Fern’s appearance when I last visited her at home.  Her voice was weak as she lay in what would soon be her deathbed.  She was deeply jaundiced from blockage of her bile ducts and she was literally just skin and bones.  Fortunately she was free of pain.  With a whimsical smile she half pleaded with me, “David, if only I could have a hot dog.”  I resisted going out to buy her one, knowing that Milt was clinging desperately to the low-protein diet.  I had such an urge to crawl in bed with Fern just to hold and comfort her – and myself.

Three days later Fern lapsed into a coma.  Milt finally relented, restraining himself from starting high calorie intravenous infusions.  Fern was dead in two more days.  Poor Fern.  How she had yearned for mutual consolation with Milt, something Milt couldn’t handle.  And lastly, she had been denied the opportunity to say goodbye.

I have often wondered if I had sought a replacement for myself, a physician less emotionally involved, would the situation have been different?  Could Milt have been brought to appreciate Fern’s need for support with her dying process rather than being bypassed as he fought her disease?   My lame excuse was that I was certain that none of my colleagues could have thwarted Milt’s steamroller approach any better than I.  Thirty years later I find that stance untenable.