Attempted

Last week a 38 year old woman was convicted of attempted murder for withholding medications from her 9 year old son. The full details of the story I am about to discuss are found here: http://www.boston.com/news/local/breaking_news/2011/04/jury_in_kristen.html?p1=News_links . I am fascinated by this story for several reasons. First, while this may seem an obvious question, in truth it is not: Is it up to a parent to decide on medications for their children? There have been several famous cases in the past 30 years of Jehovah's witnesses withholding blood products from their children. And more often than not, courts have had difficulty deciding for the parents if a bad outcome resulted. The thought is generally that a child can not make a sound, informed decision for him or herself. And usually I agree with this. But Kristen LaBrie had an interesting twist to her story: Her son had cancer and was suffering. There have been many times, in my young career, when a patient with a terminal illness, sickened by medications and treatments, has decided that enough was enough. I have helped many people make the difficult decision to stop treatments when I felt they were doing more harm than good. And most patients have felt happy with their decisions and died with dignity, often in the comforts of their own homes with family nearby. Jeremy Fraser, LaBrie's son was only 9 years old when he died. The courts decided, in the end, that he could not have made a decision for himself to terminate treatment, and that his mother was remiss in making a decision to withhold treatment for him. And perhaps both are so. Or, perhaps, as the prosecutors argued, her ulterior motives of fatigue or even selfishness led her to consciously decide to end his life prematurely. But there is another option: maybe this woman and her son communicated and decided together to stop his suffering from the affects of chemotherapy including constant nausea, vomiting, pain, infections, etc. Of note, according to the article, "LaBrie was also convicted of assault and battery on a disabled person with injury, assault and battery on a child with substantial injury, and reckless endangerment of a child". This is a case with no answers. Only this woman and her now dead son really know the circumstances. But as a dad, I know one thing: we greatly underestimate the decision-making ability of children and their ability to know what they need. The defense lawyers in this case spent a lot of time painting LaBrie as an emotionally weak woman, fatigued by responsibility. Instead they might have focused on her relationship with her son, and maybe even noted that he told her clearly several times that he himself did not want the medications. You can argue with her judgement, but it's hard to argue with a sad boy, asking repeatedly to be left alone. As a juror, I would have found it difficult to charge a woman with assault and battery for withholding medications no mater what the argument. Just because he was a boy, the same rules of humanity apply. Chemotherapy is hell, anyone who has endured it knows that. Doctors know that. Kristen LaBrie knows that. And I cannot think of a more difficult circumstance than having to make your child suffer- even to save their life. In the day to day of administering those medications, it may have been easy to lost track of the long-term goal. Watching him whither, vomit, keel over, weaken- that may have played a role. And no matter what, I am appalled that the outcome of the decision in this case is prison. What Kristen LaBrie needs more than anything is psychiatric help. Regardless of the motive for her decision, she'll have to live with it for the rest of her life. That might be punishment enough.

Just like that

This evening a seventeen year old young woman was on the highway a few blocks from the hospital when, in the glare of the sunset, she hit a man walking beside his car at 60 miles an hour. He had stopped his truck and drove into the breakdown lane. He was heading back to his side of the car to get back in when she hit him. She stopped her car and got out. What she then saw will give her nightmares, therapy and bad memories for a long time. He was missing a hole in his body from where the car made impact. His arm, half of his chest, his abdomen on his right side were literally missing. He wasn't pronounced until after the parametics arrived and was still breathing for a few minutes which means that the experience of his suffering lasted 15 minutes or more in front of the girl who killed him.

This is not a horror story meant to make you nauseous or to scare you away from driving (although I'm going to think twice about the "breakdown" lane.) Instead I am thinking about the girl. Even the firemen who brought him in were distraught by what they had just seen. She had no training for this- no preparation of any kind. She was not texting or distracted by anything except the sun, and she was wearing sunglasses. She did nothing wrong. They even determined that he was in the road based on his trajectory and how the blood tracked. So what about this poor girl?

Trauma happens in an instant. One day a phone call comes and you find out some bad news. One moment everything is ok, and then it isn't. The brain handles this in many ways. Memory storage and processing is different in trauma. And the permanent connections made in reference to an event like the one described above are the type that haunt someone. Post traumatic stress disorder (PTSD) is the official name of the disease coming for our young friend. Amazingly, there has been some good progress in the field lately. New treatments, including one used tonight in the emergency room, use medications to break the connections neurologically which bind us to bad memories associated with trauma. These medications are starting to work in the field, (she received some tonight including Inderal, a Beta blocker and steroids), as soldiers returning from war are being treated with good results to-date. We tend to pity those who suffer a trauma, but make light of that suffering at the same time. After enough time, a homeless vet is seen as "crazy." But if you found out that a homeless person, in 10 years, was girl I met tonight, would it change your opinion of her "craziness?"

The best advice about trauma, is that the only preparation is a recognition that it is real and lasting. Medicine may improve techniques or medications to treat this horrible condition, but in the meantime, compassion from friends, family and the medical community will help.

A seventeen year old girl, with a boyfriend, a letter of college acceptance kept in the car so she could read it over and over with pride, good parents, siblings, means- may or may not ever recover from what she saw this evening. Life is tricky that way. Here I am with 10 years of training under my belt, and the site of this man would still shake me to the core. Imagine her. She wasn't ready for that.

Once, outside of Las Vegas, I was first upon a car crash. A truck had spun out and hit almost 10 cars. Most people were ok but one car had three corpses in it. I remember seeing three of the four family members dead and feeling awestruck and almost embarassed at the intimacy of being in a moment where I had no place. The trauma of that day still haunts me from time to time. I was early in my training, and not quite accustomed to death as a normal part of life as I am now. Besides, there was very little normal about the fact that the only survivor was a 75 year old grandmother. But it was that day that I learned my first lesson about trauma: These moments stay with you as vividly as the most vivid dream.

Now I am going to my day job, and then I go home to my children, both under 4 years old and my wife. I will try to enjoy the weekend, maybe bar-b-q. I will put some of the images I saw this week aside and carry on. I am trained to do that and I have gotten better at it over time. Meanwhile, a seventeen year old girl will be seen by teams of psychiatrists who have a short window to change her mental trajectory, and avoid a life of suffering from PTSD. Medications aside, I think the chances are slim to none. This was one of the most greusome sites one could see. And I am afraid for how she will feel when she finds out that he is a father and loving husband. Time will tell. She will have a court date to get through, a funeral to attend. She will have to apologize to his family, to come to terms with this- in light of the fact that it probably would have happened to the next driver in her lane. It's the extreme example of wrong time, wrong place.

Just like that, in the blinding shadow of sunset, many lives are changed forever.

A leak

Tonight I re-read an article in the New York Times that I saw earlier today regarding the crisis in Japan. Everyone needs to read this article. I often reflect on what it must be like to lose more than one loved one in an accident. But to lose a significant chunk of the population is far worse. As a tribute to our fellow humans in Japan, I am attaching the link which really explains hoe much trouble the country is in. Please read this article and then send some well-wishes to our friends across the ocean.

http://www.nytimes.com/2011/03/30/world/asia/30japan.html?_r=1&hp

The damage from this catastrophe hasn't even begun to be realized. Plutonium deposits in soil and 4 leaking reactors is going to make northern Japan a dangerous place for a long time, and the cancers and illnesses which emerge in the coming years will reflect that. As a physician I am really concerned that many of us are not up to date with what is going on, or understand the ramifications of this crisis to all of us. With trace amounts of radioactive rainwater in Massachusetts this week, I fear that this is going to be one of the largest disasters we've ever experienced as a planet. So this is a plea to keep up with the news.

And if you don't think this relates to my prior posts on the human body, mind and spirit, I assure you it does. I took care of a Japanese born man this morning who has been skeptical of "Western" treatments for his hepatitis for years. After calling my attention to the article above, he then told me that he was willing to undergo whatever treatments we recommended because, "life is more important now." I asked him why, expecting him to tell me that he had been scared of his mortality by the Tsunami, earthquake and nuclear devastation which befell his home country 10 days ago. Instead he offered the following fact: his three remaining siblings were all killed their town just south of Kesennuma in the waves. While some would lose their desire to live in a time of depression, my patient wanted nothing more that to carry on. I find that inspiring and real. He represents the strength of his nation to me, and I am praying that we can clear his Hepatitis C.

It is those moments, when I am offered a simple glimpse into someone's soul, that I feel the most privileged to be a physician. Fear has so many faces, but most often is worn under a mask. In my office, on days like today, the mask is off and people are just honest with themselves and with me. When we reach that point, we trust each other, and then the patient is much more open to discussing the scary items I place on my lengthy menu of recommendations. Whether its recommending tests patients initially thought they might refuse, or lifestyle changes which are incredibly difficult to make, I have found the most success in quiet moments of revelation. At the end of the day, or a busy week, or a restless month, or someone's "bad year," what people need is to be heard and to feel understood. When my patient handed me the article he was making a plea for some level of appreciation as to what this two weeks has been for him. And he was putting his guard down and letting me know that he needed more from me today than a pill. "It was beautiful, you know," he said on his way out. "My sister's home was beautiful."

With a lot of understanding, listening, and support from all of us, perhaps it can be again.

Back in action

OK, so after a LONG hiatus (well, 15 months to be exact), I return to the limelight. Not easy juggling this doctor/dad/writer thing. But that's too boring for a blog. So let me share something more interesting:

My patient today, who had no idea why his primary care physician sent him to me when he introduced himself, but who suffers from anemia, black stools and fatigue, revealed, somewhere near the end of his visit, that he wishes to be utterly left alone by doctors. He is 85, and I must confess that I don't blame the guy. The confession was actually the response to a line of leading questions, as I asked him if he was tired of doctors "poking and prodding" his body, to which he nodded emphatically, and finally made his confession. So why did I ask? The truth is, at some point in each of your lives, you might make the same decision. Whether you are conscious, elderly and able to voice this as astutely as my World War I Veteran did, or intubated in an intensive care unit, some small piece of your brain may decide that you've simply had enough. I asked because I felt that this man had had enough. He was telling me that with his body language and with his eyes.


In August, 2009, Alaska Governor Sarah Palin decided to create the term "Death Panel" in response to President Obama's proposal to fund physician visits with patients whose main purpose would be discussing end of life care. Such visits were meant to generate living wills, or documents whose purpose was to state clearly a patient's preferences for how their body would be treated should they no longer have the ability to clearly make decisions for themselves. It was a brilliant proposal. Finally some true forethought would be supported by all of those insurance dollars, and the decisions made in those visits would empower patients who sooner or later would lose the ability to be empowered. The decisions would also save boat loads of money. Most Americans have heard, in the past few years, that end of life care accounts for much of our health care dollars. This article says it best: http://www.newsweek.com/2009/09/11/the-case-for-killing-granny.html . Upwards of 20+ percent of our total health bill is spent in the last 2 weeks of life. And usually these last 2 weeks are only that long because living wills are NOT in place to protect the body from decaying in an ICU, on a mechanical ventilator. Not to say that all mechanical ventilation is a waste, but think hard about whether every death is a tragedy. Would my 85 year old really look good on a vent? Or would he be better off dying at home with a hospice nurse making him comfortable?

Your answer may seem obvious to you. You may say: "Of course I don't want the slow death! Unplug me!" But despite this, it would astound most people to see the decisions their families make when they are actually lying there, ventillated by a machine. Without the living will, someone ultimately lays on a guilt trip and someone else buys in, and suddenly 2 weeks have gone by, just like that. I used to call this "splitting" and families who split were a headache. I had to consciously not side with those in favor of discontinuing care and think hard about the fact that this was someone's mother, aunt, cousin, or friend on the table before me. Still, it was hard. Inevitably, every doctor becomes infuriated by situation which were easily salvageable by a legal living will, had the patient only thought ahead.

So then some of the skeptics out there may ask: Did I lead him into his decision not to have a colonoscopy and work up what could be a cancer? Did my own bias and opinion set the tone that ultimately decided on no intervention? I'd be a fool to say "no way." So instead I'll simply say that when I gave my 85 year old friend a pat on the back today as I said goodbye and added, "don't let anyone make your decisions for you," he turned to me. He looked at me with the kindest, most grateful eyes and said: "You listened."

Decisions, decisions..... these are what we should be making for ourselves as long as we possibly can.