Please let him go!

The phone rang and I turned over in bed glancing at the clock. It was 1:00 am and I was on-call and I hated it. I picked up the phone before my three-year old daughter decided to do so. With a mind still half asleep, I listened to the physician from the ER telling me about a 50 year old man from interior Sindh brought with abdominal pain of four days duration, an increased heart rate, low blood pressure, kidney failure and a heart working at merely 20% of its capacity. Dreading having to explore the abdomen of this very sick man, I asked for an X-ray to look for the presence of free gas in the abdomen indicating perforation of his bowel. To my relief, there was no evidence of this on the X-ray. The patient could be admitted under medical care to the ICU for stabilization with a CT scan scheduled for the next day.

The next morning, I walked to the ICU still hoping for a medical rather than a surgical cause for the patient’s abdominal pain. There he was – a well built middle aged man writhing in pain and with several tubes running in and out of his body. The eyes of my young house officers and the ICU staff followed me as I approached the patient. I knew they expected me to place my “magical” surgeon’s hand on his abdomen and determine and then eliminate the cause of the abdominal pain. The patient seemed to want the same, begging me to get rid of his pain. “Do something,” he implored.

Dr Mujtaba, his primary physician, was of the opinion that with the patient’s clinical condition it was not possible to get a CT scan. “Our CT machine is out of order and he is too sick to be moved to another hospital for the scan,” he said. Exploring his abdomen was the only choice. We argued about the risks and benefits, spoke to the family, and finally convinced ourselves to give the patient a “chance.”

It was midday when I opened his belly. All I could see was black, dead intestine staring back at me. “Almost all of his bowel is dead, I am closing him,” I declared. “Why don’t you just take it out?” the anesthesia resident suggested the impossible, peeping over the drapes. Suddenly the patient’s heart rhythm went berserk. The consultant anesthetist said, “Let’s try some medications to see if we can correct the arrhythmia. It will be a good learning experience for the residents.” The rhythm slowly returned to normal and I was able to close the abdomen and shift the patient, still alive, to the ICU.

“Please let him go in peace,” I requested Dr Mujtaba on the phone. “Let me think,” was the answer. “What do you want to think about? The pathology is incompatible with life,” I almost screamed at him. “Allah can do miracles,” said Dr Mujtaba. “What miracle? His intestines are dead, he cannot survive with dead intestine, just do not give him any more medications to keep his heart going. Let him go.” “Well, let’s discuss it,” he said, and the argument continued.

The next morning I walked into the ICU hoping that the patient’s misery was over. But there he was, screaming and grunting with a dropping BP and a rocketing heart rate. “Please let him go,” I told the ICU in charge. “I need to ask Dr. Mujtaba, the patient is under his care,” was the reply. “But you know it is futile and he is in pain,” I insisted again before leaving.

The patient was finally allowed to go the next day, dozing off, grunting and drenched in perspiration to his death. As I stood there I wondered about the utility and the futility of treatments we offer, and our reluctance to accept when we have lost the battle.