Which is why I rush to intensive care when I hear that one of my long-term patients has been admitted overnight.
While I was away, her disease progressed. She had begun aggressive chemotherapy and days later, she fell ill. Expecting a conversation about a temporary setback, I encounter a gravely ill woman who is intubated, with failing organs, on maximal life support.
Her family has been allowed in for a glimpse. Our long association makes the exchange hard. I tell them that the next 24 hours will be critical and even if she survives, there is difficulty ahead.
The misgivings have already begun – should she have had the chemo? How could a person go from working to dying in a matter of days? Did we or they miss a red flag? Her husband and children ask probing questions, but they are polite, restrained and incredibly gracious.
We’re so glad you’re back, the husband says. She missed you. I sense genuine affection but also the silent hope that now that I am back I will unravel the disaster. The responsibility feels enormous. Behind the masks and shields, our eyes are moist.
A few hours later, the intensive care doctor calls.
She’s very unwell, he says before getting to the real point.
“I am asking you if we can make an early call to palliate and discharge her from ICU.”
My disbelief must be open because it prompts the rueful explanation that a Covid patient needs an intensive care bed.
The pieces fall together instantly. With intensive care at capacity, I am being asked to move my patient to make room for another. “After all, your patient does have incurable cancer.”
My bile rises. And even as I know it’s a petty question, I can’t help asking: “Is the Covid patient vaccinated?”
“No,” he says wearily. “That’s why he is so sick.”
Recriminations flood my mind, but this is no time for argument. I have deep regard for an old colleague who feels ethically conflicted and is asking for my help. I am torn between respecting his predicament and honouring my patient.
He agrees that absent a pandemic, if I had suggested withdrawing care, he would have counselled hanging on a little longer. And he concedes that while many of my patients die prematurely, it is important for the family to know that we did all we could. To change course merely hours after our bedside conversation would multiply this family’s grief. In turn, I understand that for a chance at survival, the Covid patient needs a ventilator.
“So, let’s make your position really clear for the night shift.”
By nature, I seek consensus and I’d like nothing more than to relieve my colleague’s obvious stress. But in a career filled with ethical dilemmas, this one really tugs at me. Only my word stands between the trajectory of a patient’s life and how her family will forever recall the experience. I am staggered by a power that I never sought, and it makes me queasy.
Keeping my voice steady, I say: “If you are asking for my permission to withdraw care tonight, I can’t give it. My patient may have cancer, but she deserves a chance.”
As I worry about alienating him, his voice breaks.
“I hope that if asked, my parent’s oncologist would make the exact same decision.”
The revelation leaves me speechless but with patients to see, there will have to be another time to ask after him.
Much is being said about the courage and sacrifice of health professionals to keep the healthcare system running but almost all of us would rather be on the frontline than anywhere else. When we enter the profession, we consecrate ourselves to serving humanity – there could not be a better time to do this. From the students rolling up their sleeves to the specialists redirected to treat Covid patients, not to mention all the nurses, paramedics and service staff sustaining a threatened workforce, this is an extraordinary and privileged time to be on the frontline.
But truth be told, we will spare the kitchen orchestra and the free drinks in exchange for a genuine reckoning with the difficulties we are facing. Often, medicine, needs to fix up its own troubles. But this time, there is something every individual has the power to do.
There is strong evidence of the efficacy of vaccines in protecting against severe illness and death. Even with the more infectious Omicron variant, the fully vaccinated are less unwell and have a greater chance of leaving hospital for home.
The collective request from a concerned and tired workforce to the public is: get vaccinated, get your booster and keep up sensible precautions. No one wants to be in the invidious position of deciding whether to save you or the next patient. (Yes, rationing happens everywhere but it doesn’t have to be as egregious.)
My patient died quickly in intensive care. When we spoke, her family was grateful for our compassion and care and could not fault the system.
We don’t know what happened to the other patient. If he endured a prolonged wait, his family might feel let down by the delay, though his certain extended stay in intensive care will impact the next patient.
I doubt this will be any consolation to anyone, least of all those who must actually make the difficult decisions.