The AAS Ethics Committee held its first annual Artwork and Essay Contest in 2021 – the topic for the essay contest was “What is the most challenging ethical issue, personal or professional, you have encountered in the COVID era?” The winning essay and artwork were selected by the Ethics Committee and will be published in the October issue of the Journal of Surgical Research. But we also want to share many of the powerful entries we received for this contest, so look for more of these essays to post as blog articles between now and the 2022 ASC – thank you to everyone who participated in the contest!
Krista Haines, AAS Committee Chair & JJ Jackman, AAS Executive Director
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In 2019, we moved my grandfather to an assisted-living facility. None of us were particularly excited for the change—especially him. However, the truth of his age, a resolute stubbornness to continue living alone, and a small Navy pension settled us in this particular enclave of South Jersey. While not ideal, it was tolerable and realistic, a drab interior that was both within our means and a reasonable driving distance. By April of 2020, the COVID pandemic had taken a stronghold in the Northeast. Now the crowded, outdated brick building that housed my grandfather was a dangerous place for any 96-year-old.
Before we had time to brainstorm extraction strategies, my grandfather called saying he was especially tired. A negative COVID test provided false reassurance, and soon he was in the Emergency Department. That evening, when his oxygen saturation began to drop, everyone focused on George Burlotos. Even so, the physicians and my family were appending his hospitalization to different histories. The ambiguous nature of COVID made prognostication difficult and widened the gap between my family’s view of the situation and that of the physicians. As the only person with medical training in my family, I became the translator between two divergent narratives.
When the doctors suggested we remove the BiPAP, my family was understandably hesitant. They knew that my grandfather had overcome worse situations. He had left a rural village at age 16 and had arrived in New Jersey speaking no English. He had survived the most infamous battles of the Pacific Theater. He had anchored the family since my grandmother’s death 30 years ago. Before the pandemic, he lived independently with an enviable social circle, enjoying his first year of retirement from his work as a television host. He had even spent precious minutes before going on BiPAP characteristically bragging about his grandchildren—surely an indicator of a good prognosis. Our patriarch now dying of a viral illness seemed highly improbable. Yet, he was.
In the depths of my clinical year, I knew the contrasting clinical narrative. I imagined myself presenting this patient. It came was uncomfortably brief.
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“A 96-year-old male with multiple comorbidities and a positive COVID PCR, accepted to the ICU from the ED with worsening hypoxemia despite aggressive BiPAP.”
As a promising medical student, I anticipate the next question.
“Code Status?” The attending interjects.
“DNAR,” I reply.
I would then move on to a review of organ systems, without time to add that the family desires to pursue aggressive treatment short of intubation, as long as it would not cause significant harm.
Another page requesting an ICU bed demands my attending’s attention. I skip to the plan.
“We should set up a call with the family to review goals of care. He is unlikely to do well, and BiPAP will not change his outcome.”
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I was stuck, caught between the rationality of my clinical experience and the emotional tethers of familial bonds. I knew that my grandfather was dying. My family needed more time to accept this; they hadn’t spent the last year living in the hospital, where death had become routine. I also knew that the hospitals in New Jersey were at capacity. They needed beds and my family needed time, and I was caught in the middle.
The principles of medical ethics I had been taught now seemed like conflicting road signs in a foreign language. Patient autonomy, a central tenet of medical ethics, provided clarity to the physicians but did little for my family. Yes, he had a DNAR, but he had also consented to BiPAP in the ED. Each additional day of BiPAP blurred the line between treatment and resuscitation.
Beneficence for my grandfather and my family came in conflict with the just allocation of resources. My grandfather was dying, and my family needed additional time for closure. He also occupied an ICU bed, a precious commodity during the pandemic. Non-maleficence, to which I had sworn the Hippocratic Oath, is simple in theory, but obscure in practice. BiPAP kept my grandfather alive, potentially prolonging his suffering. Removing the BiPAP would cause him to pass, but would leave my family feeling as if my grandfather had not been given a chance to recover.
When his labs pointed to imminent renal failure, I withheld the vivid imagery that flooded my mind. While sedation and the rhythmical ticking of the vital monitors provided a false veil of tranquility, I knew my grandfather was suffering. Searching for words for my family, I mustered one true sentence, “It’s time.”
Despite that, time passed before arriving at a plan that my family and the medical team would agree to. The change came with a new attending. My family had asked the doctors if they thought my grandfather was uncomfortable. This particular physician refrained from reciting meaningless lab values or test results, opting for a different approach.
“If it were my father, I would remove his breathing mask,” he said in plain, human-centered language.
With that valiantly simple phrase, he conveyed something to my family that had remained elusive—my grandfather was suffering, and we were keeping him alive. Next, he asked, “What would help your family be ready for your grandfather’s passing?”
Together, we decided that my father would drive to New Jersey to remove the BiPAP. That night, I said goodbye over a pixelated video call. Exhaustion dampened tears as my mind slowly returned to my body. Watching my tight-knit Greek family go through the passing of our patriarch alone, each quarantining in the silence of their respective homes, added to the surreal quality of the experience.
My grandfather taught me many lessons. Through his passing, I learned how I will approach these conversations as a future physician. First, I will learn the family’s story of the patient. Then, I will tell the medical story plainly and with courage. Lastly, I will work to write the next chapter together with the family, one that we can both agree on.