Failure is not an Option, it is a Certainty

It wasn’t supposed to end this way.

The CT scan of his lungs was supposed to be normal. Joe did not have any symptoms of cancer, no shortness of breath or unexplained weight loss. He was completely healthy. Nevertheless, new guidelines for lung cancer screening had just been announced and although he felt fine he fell within the screening parameters. I followed those guidelines and ordered a lung scan.

The results were a surprise. He had a mass in his lungs that was unquestionably cancerous in appearance. The news was bad but there was cause for hope. The scan seemed to have done its job and caught the cancer in time. The tumor appeared to be of an operable size and there was no evidence of spread. I was confident that Joe would be okay.

The surgeon shared my optimism and scheduled a resection of the tumor for the following week. The patient was upbeat, grateful that his cancer had been discovered early. He was nearing retirement and was looking forward to many more years with his family confident that our early diagnosis was going to give him those years. He felt so healthy that the day before the procedure he spent time with his grandson shooting baskets in his driveway.

We were all proven wrong. The surgery did not go well. The tumor was much larger than expected and was wrapped around one of the bronchi. Simple removal was impossible. The planned wedge resection gave way to a resection of the entire upper lobe of his lung. It was going to be a difficult recovery.

It was worse than difficult. Each day seemed to bring a new complication. We learned that his years of smoking had taken a much greater than expected toll on his lungs. He had more COPD than his tests had suggested, and the lungs he had left struggled to meet the oxygen demands of his body. The stress of the surgery led to Acute Respiratory Distress Syndrome, a life-threatening condition that causes lungs to get stiff and hard to inflate, as well as fluid to seep into the areas where oxygen is exchanged. We could not get him off of the breathing machine. Less than a week after shooting baskets with his grandson, he was dying.

Multiple specialists were called, all of them excellent, all of whom did everything they could to halt the downward spiral. They all failed. After about a week it was clear that he would not survive. Filled with sadness I came to the hospital to deliver the news to his shell-shocked wife. Together we made the decision to remove life support and let him go. We had done our best, but we had lost.

It is a sad reality of life that doing our best does not guarantee success. Excellence does not always result in good outcomes. This is not always easy to accept. We live in a results-based society that celebrates the motto from Apollo 13- “Failure is not an option.”

The truth is that failure happens, even to the best of us. Good doctors lose patients, good drivers get in car accidents, and good parents have kids that go astray. Those of us who understand this can resist the temptation to judge others based on things they cannot control, and take comfort in knowing that God judges us not on external results, but on the heart that only he can see.

- Bart

Dogs, Squirrels, and a Wasted Life

Sadie on Squirrel Guard Duty

My dog is obsessed with squirrels. I realize all dogs are, but she has taken things to a different level. She has dialed her squirrel intensity up to 11. Her walks are less about exercise and more about squirrel hunting. Her eyes continuously scan the environment looking for the flicking tail or bounding scamper of her prey. So intent is she that she remembers the location of every previous squirrel sighting so she can return to it on following days. As she approaches the sites of previous encounters her body tenses and quivers and she strains against her leash, muscles taut, ready to launch into the chase should the animal reappear.

Lately her squirrel problem has become our problem. There seems to be a somnambulatory one that likes to traverse our back fence in the middle of the night. Our sleep is often interrupted by the sound of our dogs jumping to their feet, sprinting down the hall, and bursting through the doggy door in response to the sound of the squirrel invader.

Things have escalated. We are now at SquirrelCon 4. It seems that this squirrely night walker has now taken up residence in our neighbor’s yard. As far as Sadie is concerned this is an evil that cannot stand. She is perpetually on the lookout for it, spending hours on guard duty staring through a crack in the fence. She will not rest until her furry enemy enters its final rest. The squirrel’s death is now her primary reason for living.

As I watched her watching the fence this morning I laughed at the absurdity of her doggy behavior. The squirrel was impossibly out of her reach. There was nothing she could do to get to it, yet she gave it all of her attention.

This behavior is funny in a dog, but it is tragic for people. Looking at her I thought about the hours, days and years I have similarly wasted focusing on things that were unobtainable and out of reach. I thought of the time I spent wishing my father would realize disowning me was a mistake and hoping my mom would become sober. I recalled patient behavior I could not change, professional recognition I could not gain, and relationship problems I could not solve. I had so many thoughts about so many things I couldn’t change.  It seems that wasted attention is not merely a canine problem.

What is sad about futile attention is that it always has a cost. When we focus on the unobtainable we turn away from blessings that are within our reach. Time spent trying to change patients who were set in their ways is time I could have spent helping others who would have benefitted from my attention. Hours of thinking and planning on how I could get people to appreciate me are hours I could have spent in quality moments with the family and friends who already loved me and appreciated me.

How much better would all of our lives be if we learned this lesson. It is time to focus on the good we can do, the love we can share and the lives we can touch, and not on those things beyond our reach.

It is time to be smarter than my dog.

Bart

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Naked in College

Letitia Chai giving her thesis presentation at Cornell. from Facebook

There’s an old saying about how one can overcome anxiety when speaking in public, “Imagine your audience in their underwear.” I speak in public often but have never resorted to this tactic (perhaps because most of my presentations are done in church and such thoughts would be inappropriate.) This last week a student at Cornell University went the opposite direction. She gave her thesis presentation wearing only her underwear and asked the audience to join her.

The story is that Letitia Chai, the aforementioned student, was about to give a practice presentation of her thesis in the class “Acting in Public: Performance in Everyday Life”. As she was preparing to deliver her talk the professor commented on her attire (she was wearing very short cut-off denim shorts) and asked if that was what she was planning on wearing for her final presentation. The question did not go over well.

Ms. Chai was taken aback and offended at the perceived criticism of her appearance. She took particular umbrage at her teacher’s suggestion that her appearance was making a statement that might detract from the points Ms. Chai was trying to make. Ms. Chai stormed out of the class. A few minutes later she returned to the room and took her spot in front of the class, wearing only her bra and underwear. She later wrote how proud she was that she had stood up for “every person who has been asked to change how they look to make other people feel comfortable.”

Her story resonates with me for I had a similar conversation with a female medical student a few years ago. The student, by far one of the best I have ever taught, showed up to the office in a tight fitting blue cotton t-shirt along with white denim pants and a matching blue belt. The outfit was undeniably “cute” but it looked like something a young college student would wear on a date. It was not what would I considered professional attire. I pointed this out to her.

“You are a young woman,” I told her, “and you are asking people to trust you with their lives. Look the part.” I told her it would be easier for people to take her seriously if she was dressed seriously and that when she came to my office to see my patients I wanted her to dress as if she was interviewing for a professional position.

To her credit she received the feedback in the spirit is was given. Each day thereafter she wore either a dress or slacks and blouse. She oozed professionalism and carried herself with class. While nothing about her knowledge or skill set had changed, the perception others had of her did. It was a growth experience for her.

Over the years I have had similar conversations with other students, employees and even my children. My message is always the same. Like it our not, what we wear sends a message. Our jobs get easier when the message sent by our appearance aligns with what we hope to communicate. If we want people to think we are professional, we should dress professionally. As a physician I want to do everything I can to convince people I know what I am talking about, I do not want to give them any reason to dismiss what I say. Unlike Ms. Chai, I intentionally change my look in order to make other people feel comfortable. I do this because they are more important than I am.

This is true in every area of my life. When I give advice to a patient, it is the patient’s understanding that matters. When I deliver a sermon in church, the intent is for the audience to receive what I am saying. When I am called to the hospital to meet with a family about end of life care, it is important they believe I am an expert in the ethical issues we discuss. In each of these settings I choose my wardrobe carefully. I always where a dress shirt and tie in the office, always wear a collared shirt in church and always wear a conservative suit when I meet with families. Communication is never easy; there is no reason to make it more difficult by dressing inappropriately.

It appears this is a life lesson Ms. Chai has yet to learn. 

- Bart

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The Most Important Part of Church

A patient came in recently who I had not seen in a few years. I have known him for quite a while as we met 10 years ago at a church we attended in Irvine. We weren’t particularly close back then but he apparently thought enough of me to select me as his physician. 

As we had met a church it seemed appropriate to ask how things were going at the church he attended. He shared that they had switched churches recently and that he was now going to a different church in town. Ironically, it was a church my family had attended 15 years ago.  When I asked him why they had changed to this church his answer was a common one, that his kids were comfortable in the church's youth group.

After the visit I found myself pondering how it is that people choose a church. The common answers I have heard over the years include style of music, size of the youth group, and "relevant" or entertaining teaching from the pulpit. An answer that I have never heard is the one that should be the most important- church doctrine, the specific beliefs taught from the pulpit.

In the last few years I have seen firsthand the impact bad teaching can have on a congregation. Not too long ago I  heard a pastor in town demean the struggles some Christians have with their faith. "If reading the bible is a chore, if prayer is a struggle for you, you do not know God," he proclaimed. His casually false teaching made it difficult for people to speak truthfully about their struggles. Patients who attend the church have told me stories of having their faith questioned if the shared of any personal challenges. Guilt and shame have at times taken the place of grace.

A well known North Orange county pastor recently came to the conclusion that the Bible wasn't fully accurate. He shared with his church and his online followers that the Bible was written for specific people at a specific time and place in history, and that much of it no longer applied. I know some of his young followers took his words to heart. They "discovered" that the parts of the Bible that spoke of sexual purity no longer applied to their lives.

Both of the churches led by these pastors have been "successful." They are well attended and the pastors are loved and praised by their church members. In spite of their apparent success I fear for them. To be successful in God's eyes requires pastors two accurately proclaim God's word. Doctrine matters. Correct theology is important.

I know this is important because it was important to the Apostle Paul. When he penned letters to the pastors he trained, when he instructed them on the things to which they needed to be faithful, sound doctrine was high on the list. Several times in his letters he mentioned the importance of correct teaching. He was clearly aware that a faith filled with new believers would be susceptible to error. There was a significant danger that the tenets of the faith could be altered or lost. In this environment faithfulness to the truth was essential.

The importance of sound doctrine remains to this day. A faith without consistent beliefs is not a faith worth believing in.

Unfortunately Paul’s admonitions about sound doctrine have lost emphasis in many churches. The focus is on acts of service and self improvement instead of on right thinking about God. As important as good deeds are, the reality is that if our theology is not correct we are nothing more than a social club. Why we do what we do matters. What we believe matters. We cannot be people of faith if we do not even know what we believe in.

-Bart

Life, Death, and a Little Boy Named Alfie

Alfie Evans died today. You may have heard his story. He was in a coma for over a year. His parents wanted life support continued, but a court ruled otherwise. His story and passing illustrate the challenges all physicians face in dealing with death. Here are my thoughts-

I deal with death on a regular basis. All doctors do, but in my role of Ethics Chairman at my hospital I often have end of life discussions with dying patients and their families. All of these conversations are difficult. I am only called to assist when there is conflict between physicians and families that cannot be resolved or when families cannot agree on how to proceed.

The most common consultation requests are in cases where doctors have concluded that there is nothing more to be done and recovery is impossible, yet families believe hope remains. When they believe additional treatments and life-prolonging interventions will only prolong death and increase suffering doctors recommend stepping back and allowing natural death to occur. Families often believe that letting go is the same as actively killing someone and thus cannot accept the doctor’s recommendations. When these impasses cannot be resolved, they call me.

I have been involved in dozens of these conversations. While each situation is unique they all share common characteristics. Foremost among them are differing views on death and what it means to be alive.

Doctors, in particular critical care physicians, see death all of the time. They see the signs of its coming and recognize its inevitable progression. They know the signs of recovery and survival, and in fact search for these signs relentlessly. They long to cure and heal but learned early on in practice that there are some battles that cannot be won. When recovery and restoration are no longer possible they turn their attention to the good that remains, the ability to provide comfort and dignity as a fellow human being passes from this life.

The families of patients sometimes see things differently. They see someone they love lying in a bed, someone they cannot bear to lose. They know death happens but they cannot believe or accept that it is happening to their loved one at this time. They have heard and read of miraculous recoveries and have profound hope in the power of love and the will to live. They “know” that at any moment things could change, that their family member could return. Even if full recovery isn’t possible, the chance of one more smile, one more word, or one more touch seems worth fighting for.

This hope for a miracle can lead them to see hopeful signs where no hope exists. Reflexive responses such as grimaces, grunts, and the movement of a headare evidence that “she is still in there!” or that “he can hear us!” The grasp reflex, present after only four months of development in the uterus, is interpreted as a reassuring squeeze, instead of a primitive reflex that means nothing at all. These false signs of hope become the evidence that doctors are giving up too early, proof that the fight should continue.

Love, compassion and mercy compel physicians to speak truth in these circumstances. When this truth is not accepted people like me are often the final messenger. My suit and tie and title of Ethics Chairman provide extra gravitas to words others have spoken and communicate a level of seriousness and concern families need to hear. Referencing our shared promise to “Do no harm,” I remind families that prolonging suffering and futile care are things we cannot and will not do. There are times when there is a moral and ethical imperative for physicians to compassionately say, “No.”

These conversations are always difficult but they are times when the burden is more bearable. When the patient is a nonagenarian victim of a massive stroke, bed bound and ventilator dependent, there is a higher degree of clarity. We know that death is only a few years away for the healthiest of 95 year olds, which eases the fear of error. Conversations with multiple patients near the end of their lives give us confidence that it would be cruel to artificially force someone to a prolonged death tube-fed and non-communicative in a nursing home.

The younger the patient is the more difficult these conversations become. There is a dramatic difference between saying goodbye to an elderly grandparent and saying goodbye to one’s little boy. The natural fear and intense emotions that come with a dying child can overwhelm the coping mechanisms of any parent. Desperate desire and gargantuan grief, when combined with the false signs of hope often displayed by a vegetative patient, make it impossible for some loving parents to let go.

This appears to have been the case with the parents of Alfie Evans, the 23-month old infant who died today in a hospital in England. Alfie had a degenerative neurological condition that resulted in severe development delay (he never progressed beyond the level of a 2-month old child). His condition led to severe seizures when he was 6 months old. MRI scans and EEG tests demonstrated significant brain damage was already present at the time of his first seizures. He was placed on a ventilator and a feeding tube was inserted. In spite of aggressive medical treatment the neurologic condition and resultant epilepsy progressed and caused continued damage to his brain tissue.

Over the course of the last 17 months extensive medical testing and analysis was done on little Alfie. Although it was evident to physicians early that recovery was not possible they continued to explore every available option. Ultimately, when later MRI scans showed that brain tissue was decreasing and being replaced with fluids, the medical team reached the appropriate conclusion that continued care was futile. While they could not know with certainty whether or not Alfie could experience pain it seemed clear that if he couldn’t experience pain it was because he had no meaningful brain function remaining. Worse, if he could experience pain, he would experience it with no hope of recovery. Neither option supported continued care. It was time to let him go.

All of this was presented to the family and the doctors said it was time to withdraw life support. The court documents articulately describe his parent’s response-

“The Fathers core dilemma, from which he struggles to escape, is that whilst he recognises and understands fully that the weight of the evidence spells out the futility of Alfie’s situation he is, as a father, unable to relinquish hope.”

Alfie’s family could not let go. A careful review of the case reveals the innumerable obstacles they faced as they struggled to process the tragedy and how they should respond. Alfie was their only child, and they were just 19 and 20 years old. They received an overwhelming amount of outside input from uninvolved parties, some of whom seemed more interested in personal agendas than they did in their suffering. The parents were trapped in the middle of a hurricane of opinions and emotions with no way of escape. It was ultimately the courts who determined the path that would be followed. The decision was made for them. Alfie was removed from life support and died this morning.

Much has been written about Alfie’s case, most of it focused on the issue of parental rights regarding decisions to continue care. I will leave those arguments to others. For me, Alfie and his parents demonstrate a reality that is a part of all medical care. Patients and families are often forced to make decisions they are not equipped to make.

When these circumstances arise it is up to physicians to love, serve and support the patients under their care, to do good whenever possible. When that is no longer possible, to do no harm.

Bart

If you are interested in the details of the case, I recommend you read the judge's decision. You can find it here.