It seemed as if the patient would die.
Awaiting a heart transplant, he developed an infection and was in a drug-induced coma, on a ventilator. He went into cardiac arrest, received CPR and was stabilized.
Even so, his fate appeared dire. Yet, a year later, the doctor, expecting to find the same patient in that same gray territory between life and death, now meets a cheerful man sitting upright and enjoying his breakfast.
A heart transplant had restored him to health.
We meet this patient in Dr. Lauren Van Scoy's book, DNR: Do Not Resuscitate, along with four others, all unusual cases, all presenting dilemmas that so often confront doctors and families of patients in critical-care units.
Their stories reflect the anguished choices that end-of-life care requires — especially poignant at the beginning of a new Jewish year in which thoughts of life for the coming year are mapped out and important decisions planned for its meaning.
The patients in the book are young, middle-aged and elderly. They have come to the hospital for varying reasons: heart disease, cystic fibrosis and lung cancer, among others. And their families respond with a medley of hope, helplessness, calm, anger, resignation.
Think Now Before It's too Late
Van Scoy, currently associated with Hahnemann University Hospital and in fellowship training in pulmonary and critical care at Drexel University College of Medicine, explains that DNR expresses her own opinions and was written outside the scope of her employment at Hahnemann and Drexel.
It grew out of the need, as she states in the introduction, to "plant a seed" in the reader's "mind about some of the medical situations" he or she may face.
Particularly poignant for Van Scoy is the story of Patrick, 19, a cystic fibrosis patient prepared beyond his years for what he would face. He tries as much as possible to have a normal life, enjoy a vacation and have a girlfriend whom he hopes to marry.
However, diagnosed with a killer infection, he asks to be allowed to receive hospice care rather than yet again have to fight another battle with his disease.
Even so, his decision is in many ways life-affirming. He invites family and friends to a "party," to give them and him the chance to say goodbye. He is able to convince his family to accept this choice and to let go.
On the opposite end of the spectrum, the family of a patient identified in the book as Mrs. Chandler, a woman of 88 with lung cancer that has metastasized into her bones, insists on every possible measure being taken to keep her alive, despite the futility of these measures and the intractability of her pain.
Fearful of losing their mother, the children's fear explodes in anger and contradictory demands, severely trying the patience of the medical staff. The daughter insists that Mrs. Chandler was asked in the emergency room whether she wanted to be resuscitated and said yes.
But whether anyone — patient or family — is fully prepared for what this means in terms of her care, is increasingly uncertain. Eventually, the family has to let go, to accept; as her son expresses it, "We have done all we can do. We want to let her rest."
This story, although a painful one for Van Scoy to share, offers an important object lesson for others in similar situations.
The underlying question to the reader, in all of these stories, is one that many prefer to push aside: Are you prepared for the decisions that you or loved ones will make on your behalf at the end of your life?
The question is there, and it may not wait until old age.
Dr. Robert Promisloff, pulmonary/critical care physician and chair of the ethics committee at Hahnemann University Hospital, sees Van Scoy's book as a valuable resource in its accessibility. Through "storytelling," it brings out "the need for discussing issues we see every day," he explains.
"People are living longer, have more options. They can live into their 90s, receive transplants — but eventually, the end will come."
For some, having access to a rabbi or other clergy member can help them face death more peacefully.
People tend to do better, says Promisloff, "if they have faith," and are able to see "something beyond their own life."
Again, of course, as with definitions of what makes for quality of life, faith is an individual matter, and is not something that can be forced on someone.
Ultimately, says Van Scoy, "The best we can do is listen and provide religious counseling when necessary."