My friend who became my patient

Maria Valois, MD

CMAJ 1999;161:1485-6

Some two years ago, as the end of my second year of residency approached, my coping skills were wearing thinner by the week. During the previous months I had endured a long string of personal disasters and was simply running short of motivation and resilience.

Photo by: Hugh Malcolm

I was in the last 2 weeks of a medical ICU rotation before beginning a month's holidays, which would involve a move to a new apartment that I did not really like. I was sharing duties with colleagues/hyenas who were eager to upstage anyone in their pursuit of a select fellowship. So, from several points of view other than academic, the rotation was not easy. That morning — like every morning — I picked up my scattered bits and pieces of courage and went to work, smiling at everyone. No names on the list of new patients stood out, and I followed the team as we got ready for morning rounds.

The team started with the last admission, the sickest patient. I focused on the details of the medical history and frantically took notes, not really paying attention to the patient. Then the history started to assume a more familiar shape; before my colleague even got to the main point, I asked: "Is this patient on dialysis ?" At that moment, the face grew familiar before my eyes. There, lying intubated, comatose and almost unrecognizably swollen, was a friend of mine, a women I had met a few years ago during medical school. I hadn't made the connection earlier because she was listed under her Catholic first name, which we never used.

Indeed, Hi was my best friend's sister; the 2 shared an apartment during our medical school years. The first night that Hi was supposed to join us at the movies, Diane told me her story. As a teenager, Hi had glomerulonephritis and her kidney function never recuperated. She had been on dialysis ever since.

Freedom was a constant theme for Hi, from small talk to deep conversation. Diane apologized ahead of time, because she knew that the subject was likely to be discussed that night and because she also anticipated that Hi's craving for ice would drag us from one convenience store to the next in her quest to devour Popsicles. Hi was making a transition to intraperitoneal dialysis, something she thought would buy her time to do things, to meet people, to be happy.

That night, her misery was bleeding from every pore. She could not reconcile the chains of dialysis with any of the projects that she was dreaming about or the person she wanted to be. I listened politely and came home in awe of her courage and determination to make things work despite the tremendous obstacles. She had taught me a lesson.

During medical school Hi joined us socially a few times, and we always chatted for a minute or two whenever I called Diane. At Diane's wedding, Hi and I decided we could get together during her dialysis since she was being treated at the same Montreal hospital where I was doing my residency in internal medicine. She had reverted to hemodialysis because the peritoneal method had led to multiple admissions because of peritonitis. Although this was a university hospital with clinical teaching units, she was always admitted privately under her nephrologist's name because she could not bear being a "teaching case." She tried to laugh about the situation, but her giggles seemed uncomfortable and distinctly lacked heart.

Since being back on hemodialysis, there had been no admission for almost a year, something that made her proud. She was still savouring the taste of being freed from the commitments of undergoing peritoneal dialysis 4 times a day. She was frightfully thin and, because her dialysis was scheduled at 4 am, the bags under her eyes could always compete with those of any medical resident.

I dropped by a few times on my in-house calls, whenever fires had been put out and before new ones burst out. We indulged in "surgery-bashing parties," where we called the surgeons unflattering names and said: "No Sir, not for me. What fool would trust them anyway?"

She dreaded a kidney transplant just as I was avoiding a third hip surgery. We connected on that level and we both instinctively drowned our fears in sarcasm. We drank to her second refusal of a matching kidney, calling it "a sweet victory."

How did we go from our light chats over her only chance at chocolate each week to my suddenly being on the team taking care of her? She had skipped a dialysis session, seized on her way to hospital and was intubated in the ER on the day that I was postcall. So, by the morning that I recognized her she was slightly more than 12 hours postintubation and showing no signs of cerebral activity.

Neurology was consulted, of course, and on the body of my friend the entire team learned how to diagnose cerebral death. I do not remember what was said, but I do remember mumbling to myself: "I am sorry. I am so sorry." When Diane joined me — she was now doing her residency in Quebec City, a 3-hour drive away — she confirmed that Hi would never have accepted such a situation. I knew this already because I had grown to know Hi quite well and was aware of her feelings toward the medical world and her ultrasensitivity about her privacy.

As news of a cerebral death spread in the hospital, seemingly endless groups of medical students came to see "the oculocephalic" and the caloric tests that were being performed, just so they could say that they once saw it. I felt sick to my stomach every time a new group passed the door. I had 2 choices: to let it happen or to fight for what I knew were the wishes of a dear friend.

The toughest decision of my medical career was to choose the former over the latter and remain silent, all the while knowing that Hi would never have accepted this situation. I wanted to stop the circus, but it was impossible without causing a scene and running the risk of compromising my position with many of the attending physicians and my fellow residents. To this day I feel that I betrayed my friend by letting her become the guinea pig she never wanted to be. Keeping silent meant breaking my vow to help my patients and my friends — always. I had never pictured a situation in which a person would be both, and that I would be breaking 2 of my most important rules at the same time.

On my weekend call the second set of brain-death tests — the final one — was scheduled. I did not want to do it, but Hi's family approached me. "We are so glad that it is you," they told me. "It makes things easier." So I did it, and when I wrote the declaration of brain death in the chart, my own emotional Glasgow score was 3.

Several unanswered questions haunt me. Did Hi commit suicide because she could not go on? Did she skip dialysis on purpose to put an end to it? How did I miss the clues? What were the clues? She had once mentioned an acquaintance she had met through dialysis who had committed suicide by drinking orange juice. Had she been giving me a clue? Would things have been easier if I hadn't supported her refusal of the transplant? Would that surgery have given her the chance to lead a close-to-normal life? Why didn't I speak as a doctor instead of as a friend, as a soul mate? After failing our friendship so badly I had to make it up to her, and I failed yet again by letting all these people look on as the nurse interrupted rounds to change Hi's sanitary napkin and place a clean piqué.

Hi dreamed of being a free spirit. To her this meant a new kidney; to me it meant new legs that would allow me to stand without pain. I witnessed the chains of dialysis being swapped for the chains of being a case. And I did nothing to stop it. When her heart stopped beating, I saw it as the beginning of a life that could not be worse than the prison she had felt trapped in. For someone to whom freedom meant so much, death could not be sad. Incidentally, Diane told me that this tragedy brought her closer to her father than ever before, a fact I could appreciate because I had lost mine before I had the chance to be close to him.

I am less sad about the fact that Hi died than about the circumstances surrounding her death and my failure to stop the medical machine that had reduced her to an interesting case. I am sad that I did not stand up for her. At the funeral home, I nevertheless tried to be there for Diane and her brother, who had just passed his Royal College oral examination the day before she died and was sobbing uncontrollably: "It was supposed to be the happiest day of my life."

More than 2 years down the road, my thoughts are often drawn to Hi, especially as the seasons change and the passing of time becomes more obvious. When melancholy takes over, I picture her soul in the wind, saying hello by moving thousands of leaves with a single breath, singing of her long-awaited freedom. In moments of discouragement, I beg for guidance and for any sign that this precious freedom will someday be mine as well, and that whatever lies beyond there is the promised land of a pain-free existence.

I have to live with my decision to let medical education supersede human dignity, and it is a burden I will carry to my grave. My lack of religious inclination makes forgiveness an improbable outcome. Each time I long for one last chance to hear her laugh and share her smile, I no longer wonder when, but if, it will ever stop hurting.

Dedicated to the fond memory of Harold, my highly qualified zootherapist, for the dearly missed therapy of his pink nose and green eyes whenever I had the blues.

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