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A First Encounter

“I beg of you, Doctor, please don’t let Dr. Moore see my mother again. My sisters and I do not want him talking with us anymore.”

So concluded my first conversation with Samir Zadeh. Our meeting had been purely accidental; as I walked onto the elevator going down from the Surgical ICU, he and one of his sisters (her name, I would learn, was Nadira) were already on, coming down from another one of our hospital’s ICUs, from a floor above. Samir was a man in his early 50s, and his sister, whom I would learn was actually a few years older, appeared younger than he. They were talking quietly when the doors opened, but as is often the case in elevators, especially in a hospital, as soon as I entered, their conversation stopped. We rode down to the bottom floor in silence. As we exited, I let them go first, a courtesy I had been taught by my parents, and they both thanked me, in the usual social way, and walked out into the lobby and then out of the building. I walked the same way.

It was when we were about 25 feet from the building that Mr. Zadeh and his sister stopped, so that I caught up to them. As I did, Mr. Zadeh, a large man, maybe 6 feet tall and 250 pounds, with thinning hair and a well-groomed mustache, turned and said my name aloud, “Dr. Finder, may you be so kind as to talk?”

“Uh, sure,” I replied. “Have we met?”

It was a reflex to ask him that because in that split second of his turning and saying my name, I was also a bit taken off guard and wondered how he knew who I was. After all, other than having seen him on the elevator, I couldn’t recall having previously met him.

“No, and my apology for being so abrupt. But I saw on your name badge that you are the Director of Ethics and so I was thinking, Dr. Moore, he might work under you?”

Steve Moore is one of my colleagues.

“Well, yes. Dr. Moore is my colleague. How do you know him?”

And with that, Mr. Zadeh began to tell me about his mother who was a patient in one of our ICUs. A woman of 83, she had been diagnosed with lung cancer 3 years ago, but while other physicians had recommended she pursue hospice (“Those doctors she saw, they told her her cancer was an aggressive kind and already had spread too far,” he stated), Mr. Zadeh and his sisters (Nadira, who was the woman with Mr. Zadeh and whom he introduced to me, although she mostly just stood by quietly while her brother spoke, and Farzana, the oldest who, he said, was currently up with her mother) found an oncologist (Dr. Said Broukhim) who was willing to pursue aggressive treatments. “And,” Nadira interjected, “he has given our mother three extra years.”

Mr. Zadeh continued that his mother had done well and even though she’d been sick, she had continued to take care of his father—her husband—who had dementia and had been in decline for years (I would learn later that several months ago he’d been hospitalized and then gone to rehab, from which he was scheduled to be discharged soon. In addition to helping take care of their mother, Mr. Zadeh and his sisters had also been dealing with their father’s illness).

“Two weeks ago,” Mr. Zadeh now said, “I stopped by to see my mother, and as soon as I entered her home I knew something was not right. And I found her in her bed, confused and not able to speak. I tell you, Dr. Finder, I was very afraid, to see my mother like this. So I called 911 and they sent an ambulance and we came to your hospital and my mother was admitted.”

As Mr. Zadeh was relaying this to me, I began to remember Steve telling me about Mrs. Hamadani (whose last name, it turned out, was different from her son’s). Steve had initially seen her back when she was first in the hospital 3 years ago, even before Dr. Broukhim became her oncologist. At that time, her neurologist, who had been following her because of her having Parkinson’s, had requested ethics consultation because he believed the family’s request for aggressive intervention for her then newly diagnosed cancer was inappropriate; beyond her Parkinson’s and the mets to her liver and brain, she also suffered from CHF and renal insufficiency, if I was remembering correctly. But I did remember that Steve had said that this neurologist was the one who had suggested hospice, and that Mr. Zadeh and his sisters had vilified him, actually shouting him out of their mother’s room and yelling down the hall that he was fired. It had been quite a scene from what Steve had learned and later told me, and several of the nurses had actually contemplated calling security. The Neurologist, though, unfazed, simply called us and asked for an ethics consultation, and Steve had picked it up. In an effort to help this family, Steve was the one who had actually contacted Dr. Broukhim to see if he’d be willing to talk with Mr. Zadeh and his sisters. Broukhim had a reputation of being extremely aggressive—often too much so for some of the others physicians who frequently interacted with him—but he was beloved by his patients.

And while Mr. Zadeh did not mention it to me now, I knew his mother had been in and out of the hospital five times over the past 3 years. I knew this because each time she came in, she would pop up on our list (one of the benefits of an electronic medical record is that you can keep track of when patients with whom you’ve been involved return to the hospital) and Steve would stop by and check in with her and her children. More importantly, Steve and I had talked about what had happened on several of those admissions, had even used it as an example in one of our Clinical Ethics Consultation Service Review sessions, namely, someone involved in her care—perhaps the consulting nephrologists or the ICU attending or the Social Worker—would informally ask Steve, when they saw that he was checking in on Mrs. Hamadani, to more formally intervene because they were concerned that Mrs. Hamadani was suffering, that continued intervention was futile, that her children were making bad decisions. And Steve would then talk to the various physicians involved, including Dr. Broukhim, in order to learn if there was a shared opinion about the possible inappropriateness of Mrs. Hamadani’s treatment plan, but there never was. Moreover, no one was willing to take the lead and more officially state, in Mrs. Hamadani’s medical record or at a family care conference, that continued treatment would not be appropriate, should not be pursued. So Steve simply followed along.

Then, 2 weeks ago, when Mrs. Hamadani was admitted, Dr. Broukhim had immediately called Steve and asked for his help; he now felt there was nothing more he could do, that Mrs. Hamadani was at the end. He thus wanted Steve to help him talk with Mrs. Hamadani’s children. Broukhim also requested Palliative Care get involved and he sought input from Nephrology, Cardiology, and Neurology. I remembered Steve telling me that this may have been a first with Broukhim!

Within 2 days, all of the physicians involved in Mrs. Hamadani’s care had left notes in her chart stating that further aggressive intervention was not warranted, and that DNAR status would be appropriate. With this in hand, Dr. Broukhim had asked Steve to join him in meeting with the family.

During this family meeting, which Steve had told me about and which was held on the third day of Mrs. Hamadani’s hospitalization, Dr. Broukhim had been exceptionally clear and direct that he believed that Mrs. Hamadani was not only no longer a candidate for chemotherapy, but, for that matter, any curative intervention, that she was at the end of her life and that the best thing to do now was to keep her comfortable. Indeed, to Steve’s chagrin—because it wasn’t really accurate—Dr. Broukhim even said that Mrs. Hamadani’s condition was such that some would claim that under the hospital’s “medically inappropriate treatment” policy, to do otherwise could not be justified.

Mrs. Hamadani’s son and daughters were, Steve had told me, quite distressed by Dr. Broukhim’s report, especially this man with whom I was now conversing. And yet they expressed great appreciation for Dr. Broukhim and all that he had done to help their mother. At first Steve thought that they were ready to accept Broukhim’s recommendation to shift purely to a comfort only focus. But then, when the issue of code status was raised by Steve as a practical example of what it means to focus on comfort only, they were adamant that they were not ready to make that kind of decision. Moreover, they wanted a G-tube placed because they believed that with more aggressive nutritional intervention, their mother would be able to rally. When Dr. Broukhim told them that the extent of her disease was such that she was not a candidate for any type of surgery, and thus that a G-tube could not be safely placed, Mr. Zadeh asked that an NG tube be placed instead.

Interestingly, as I began to remember these details, Mr. Zadeh also began to tell me his version of that initial meeting with Steve, and then the subsequent two-plus weeks of his mother’s hospitalization. As I listened, I continued to remember what Steve had told me.

Specifically, at this point in that conversation on the third day of Mrs. Hamadani’s hospitalization, the tension in the room had been palpable, both in terms of Mrs. Hamadani’s children being agitated by the prospect of some sort of final decision being made not to provide additional interventions for their mother, and Dr. Broukhim being agitated by having the children ask him for more interventions and him having to say “no,” an unusual experience for him. In an effort to help defuse the moment, Steve had offered that perhaps it would not be unreasonable to place the NG, since it offered little risk and only minimal discomfort given Mrs. Hamadani’s state. But Steve also stated that he would like to know what Mr. Zadeh and his sisters were thinking such that they seemeed to be willing to proceed with aggressive intervention given Dr. Broukhim’s—and the other physicians’ as well—recommendations and concerns.

This gamble, so to speak, paid off in that Mr. Zadeh expressed appreciation to Steve for supporting their wishes for the NG while at the same time acknowledging that his question was a good one, that they really did need to give it more thought, and that they would. In the meantime, however, they still wanted their mother to be full code, and if necessary, to be transferred to the ICU. And as it turned out, several hours after the meeting, Dr. Broukhim did decide that with continued hypotension and respiratory distress, Mrs. Hamadani needed to be transferred to the ICU.

When Steve next stopped by to talk with Mr. Zadeh and his sisters a few days later, they were, he told me, more distressed than they had been during the family meeting. Still, Steve had asked them about the question with which he had left them and if they had come up with an answer yet. I also knew from Steve that while he had stopped by several more times in order to address this, each time Mr. Zadeh or one of his sisters had stated something to the effect, “now is not a good time to talk.”

Now, as I stood outside in the plaza, beyond the front doors of the hospital, Mr. Zadeh was telling me what had transpired since what I already knew had occurred, and more specifically, what had occurred not more than an hour or so earlier today.

“My mother, she is strong and after only a few days in the ICU she was well enough to go back to the floor. But the nurses there, they were not as attentive as the staff in the ICU, and my sister, Nadira, or our older sister, Farzana, or I would have to make sure they gave her medicines on time and that they fed her correctly. Let me tell you Dr. Finder, we had to watch out or she would not get the care she needs to get stronger.”

As he spoke, Mr. Zadeh was becoming more impassioned, and yet his tone was modulated; it was mostly his gestures and facial expressions that suggested to me that he was more engaged.

“Dr. Broukhim is such a caring man, we are so grateful to him. Unlike those other physicians who didn’t want to take care of our mother when she first became sick, he knew that she still had more time to be with us on this earth. And even as my mother has gotten sicker, he still has shown us hope. And he would come and visit, even in the middle of the night. My sisters and I take turns staying with my mother, and sometimes it would be 2:00 in the morning and in would come Dr. Brouhkim, to check on our mother.”

“But Dr. Finder,” Mr. Zadeh continued, “your Dr. Moore, he has pestered us, always showing up when my mother has come into the hospital, asking us if we are ready to stop. It’s as if he doesn’t know what it means to love your mother.” Mr. Zadeh’s voice now began to rise and even quiver slightly. “And then today, my mother was not doing so well, and it is, I believe, because they have not been giving her enough nutrition and so she is weak. And she began to have difficulty breathing and she had to be emergently taken back to the ICU. You look like a gentle man, Dr. Finder, and so I believe you can imagine the worry this caused for us.”

Mr. Zadeh’s sister, Nadira, was gently wiping her eyes as Mr. Zadeh spoke.

“But what do we find when we come into the ICU but Dr. Moore, standing there and talking with the nurses and doctors. And then the lady ICU doctor asks us to leave our mother’s side and to come with her and Dr. Moore into a conference room. Why would they do that when she is having trouble keeping her breath, why would they ask us to leave her side at this time? After all, Dr. Finder, we are not dumb people. We know that our mother has cancer and now she is very sick, so why would we leave her? It makes no sense.”

“But the lady doctor was very insistent and Dr. Moore too said that we needed to talk, and so Farzana, as the eldest, and I as the son, we went with Dr. Moore and the ICU doctor, but Nadira stayed with my mother because we could not leave her alone. And when we got into that conference room, I tell you Dr. Finder, I could not believe it. This lady doctor tells us that our mother is at a critical point and that we need to decide if we want her to be placed on the ventilator. But she asked as if it was not our decision, that it was she and Dr. Moore who would decide. And I told them that no decision like that needed to be made until her heart stops; then we, my sisters and I, will decide what to do.”

“And then Dr. Moore started to talk about the doctors’ belief that she was dying, that her organs are failing and that we needed to make decisions about how she would want to be treated. And so ‘why,’ I ask, ‘why are you having us sit in here instead of being with her as a family?’ And this lady doctor just sat there, and Dr. Moore once again started to talk about making decisions before my mother’s heart stops, and I said, ‘We will tell you what to do when her hearts stop, but until then, we do not want to be sitting here.’ I must apologize, Dr. Finder, I was so upset. And poor Farzana was beside herself. Is this anyway to treat someone’s mother?”

I was listening intently, trying not only to hear the words but absorb the emotion, the sense of urgency, the experience that this man, whom I had met by accident by stepping onto an elevator, was now offering to me. I made the choice to speak to him.

“I don’t think I can really imagine what that was like for you, Mr. Zadeh,” I offered, unsure what else to say, unsure whether my decision to speak now was the right thing to do. He took a somewhat deep breath and began to speak again, and so I listened once more.

“And so I asked Dr. Moore, ‘Did Frank Sinatra’s family have to have these conversations?’ It was not a nice thing to say, and I would hope no family would be faced with this kind of thing. And there was Dr. Moore, talking about what we had discussed 2 weeks ago with Dr. Broukhim and how he had come by to visit with us. But he did not visit, he simply came to get us to say what he wanted to hear. And it was too much, it was not right, and I again told Dr. Moore and the lady physician that when my mother’s heart stop, then we will decide whether to put her on the machines. And then Farzana and I got up and left so that we could be with Nadira and our mother, who, by the way, seems to be doing well with a face mask.”

Mr. Zadeh paused, but it was a longer pause than before, as if he was collecting himself, regaining his calm.

“You are a good listener, Dr. Finder, and I thank you. I believe you understand what it is like to face this sort of thing.” And then he said it: “And so I beg of you, Doctor, please don’t let Dr. Moore see my mother again. My sisters and I do not want him talking with us anymore.”

And for a second time since exiting the elevator and walking outside, I was taken aback somewhat. While there was a kind of forcefulness to Mr. Zadeh’s request, as he spoke it, both he and his sister Nadira were both looking at me not with anger nor reproach, but with eyes slightly wide and down-turned at the corners. I was struck by their sadness and apprehension, peppered with a bit of fear.

I also was not unaware that I may have just been manipulated.

Moreover, I knew I didn’t know what was really going on, that the flashes of memory I was having of Mrs. Hamadani’s situation were just that, flashes. I couldn’t be sure I was remembering accurately and while I had no reason to doubt what Mr. Zadeh had just told me, I also knew that, even if accurate, it was an accurate report of what he had been facing and experiencing; but as always, there was likely much more to the story. And so I wasn’t sure it would be the right thing to pull Steve from what was going on even though I don’t think it appropriate to force family members to talk with ethics consultants even if we continue to meet with members of the patient care team.

“I will talk with him,” I said, “and then I’ll come talk with you again too, if that’s alright.”

“Yes, thank you, Dr. Finder, thank you.”

And with that, Mr. Zadeh grabbed my hand with both of his and lightly bowed his head down, and then he and his sister continued walking in the direction they had been going, away from the hospital.

Still taken aback from this whole situation, I was unsure what to do. This was, in many ways, a quite extraordinary conversation. To begin, I had never been stopped like that before, never had a family come up to me out of the blue, in this sort of more public area, and start discussing their situation because they saw “Ethics” on my ID badge. Then there’s the fact that one of my colleagues had already been involved such that, even if not immediately, I was able, while in the conversation, to have some recognition about some of what was going on. And then, of course, the most dramatic element, to have the family ask me to intervene on their behalf in order to stop my colleague from talking with them as well as, if I understood correctly, even from checking in on their mother; that too was unprecedented.

I knew I had to talk with Steve, and I was thinking it would also probably be helpful to take a look at Mrs. Hamadani’s chart and talk with the ICU staff in order to learn more about what her medical condition looked like today. I also was thinking that it might be useful to talk with Dr. Broukhim. And, I also found myself thinking that I probably needed to find the nearest place to sit down and write out the description of what had just happened. Because I knew well from experience that as soon as I took a next step after this conversation, my recollection of it would change.

And so I chose to walk back to my office, to then sit down and write down a few notes about Mr. Zadeh and his sister Nadira stopping me and talking with me and asking me to intervene. I also was hoping that in doing so, I might provide myself with some time to think more about this conversation I’d just had and to see what might present itself as the right next step to take.

Talking with Steve

After outlining the main elements of my encounter with Mr. Zadeh and his sister, I pulled up Mrs. Hamadani’s electronic records and was able to confirm that my recollection of what had been going on with her medically, as well as some of the social dynamics surrounding her care, were as I had thought. I then called Steve.

When I recounted what had happened, he said he was not at all surprised.

“When I’ve gone to talk with Mr. Zadeh, sometimes he’s very nice and even charming, and then I’ll see him a few days later and I’m not sure if he’s sleep deprived or just really angry, but it’s clear he doesn’t want to talk with me. So I just say ‘Hi,’ and leave. And the nurses have told me horror stories, that he and his sisters hover around their mother and are always watching every little thing the nurses do, and if one does something this way but it’s not like the last nurse did, which was that way, they get upset. Some of the nurses are even refusing to take care of her anymore because of this. I guess it’s been this way every time she comes in.”

“And then this afternoon, I was up in the Unit looking into a different situation when I heard the nurses and residents talking about Mrs. Hamadani coming back over. So I started talking with them about what was going on. And then I pulled Annie Smith aside, since she’s attending this week in the Unit, to talk with her, so when they came in and they saw us talking, I’m sure it set them off a bit.” And then Steve proceeded to tell me about the meeting, and surprisingly, his recounting was not much different from what Mr. Zadeh had reported, at least in terms of the facts; while the tenor of how Mr. Zadeh had spoken was quite similar to how Mr. Zadeh had presented it to me, Steve’s version of his own presentation was not quite as Mr. Zadeh had characterized it.

As for the request that he not be involved, I wasn’t surprise at how Steve replied:

“Look, I don’t want to make matters worse for this family. I know their coming from a good place, that they want what’s best for their mother. They’re in a really bad situation and I can only imagine how difficult it must be. As you know, Broukhim is really aggressive and he sometimes gives what I think is false hopes, so I’m not surprised this family is struggling. I’m a bit surprised they saw my coming by to check on them as badgering, and I hope you don’t think that’s what I was doing…” I assured him I didn’t. “I’d just warn you that they may be using you, to avoid what we’d already agreed upon in terms of talking about why they want to code her and have the feeding tube and whatever other aggressive interventions that may be available.”

We talked a bit more about the conversations he’d had with Broukhim and the other physicians as well as a bit more about his interactions with Mrs. Hamadani’s children. Mostly, Steve told me, he’d been talking with Mr. Zadeh, although one or both of the sisters was always in the room, and he’d spoken with one of them more than the other, although he really didn’t know which one it was—“I can’t remember their names, but it was the taller one,” he said.

I would later learn this was Farzana, the eldest daughter and actually the oldest of the three siblings and the one who’d lived in the United States longest as well.

I knew Steve well enough to know that, at times, even though unintended, he does come across a bit forcefully, with a kind of intensity, because he’s really committed to this work and really believes in tying to help, so it wasn’t hard for me to imagine that even his simple act of sticking his head into Mrs. Hamadani’s room to see if now would be a good time to talk could easily be experienced as invasive. And having heard more about the situation and what Steve and Dr. Broukhim and the nurses had been discussing, I decided that it would be better if Steve stayed clear of the room.

“Of course,” I told him, “that doesn’t mean you can’t be on the Unit if other consults come up. And I think it’s OK if you want to keep talking with Broukhim since you’ve been helping him as much as anything. But really try not to put yourself in a position that the family might mis-perceive as your still being involved with them. I’ll take over that. I’m also going to give Broukhim a call since I’m thinking it may be helpful for him and I together to sit down with all three of the kids just to update them on what’s going on and to see if they have any questions.”

Steve said he was fine with that.

“But I’ve got to tell you again,” he interjected, “be careful. I don’t mean this with any disrespect, and I know it sounds bad but, this is a Persian family and they approach these things a lot differently. I’ve seen it before where they say one thing one day and then the next day it’s something different. And especially when it’s an elderly parent, they have a really hard time letting go. And it’s not just them. You’ve looked at the chart, you’ve seen who’s involved: Broukhim, Teharani, Nadouri, Hekmat. All these physicians, you know them, and you also well know most of their patients come from their own community, so even if unintentional, there are issues of professional reputation and community standing they have to deal with.”

While it could come across not as he intended, I knew Steve was not speaking out of prejudice but out of recognition that as much as anything, cultural elements here may well have been part of what was at play. I also knew we’d be talking more about what was going on with Mrs. Hamadani’s situation. I thanked him and hung up.

Based on our conversation and what Steve hold told me he knew of Mrs. Hamadani’s current medical condition (although in the ICU, she was stable, and maybe even slightly improved hemodynamically speaking) as well as what I had read in Mrs. Hamadani’s electronic record, I didn’t feel particularly pressed to do more at this point; after all, it was late in the afternoon. So I decided that come morning I’d call Dr. Broukhim as well as go to the Unit and talk with the folks there.

This was looking to be a very interesting consultation.

A Slight Delay

My plan had been, in the morning, to walk over to the ICU in which Mrs. Hamadani was located, review her paper chart, talk with the ICU team about what was going on, and try to get a hold of Dr. Broukhim. Unfortunately, my role in the institution is not limited to my clinical work, and I was called away for the day due to a number of other situations which, for a variety of reasons, could not wait. Hence, by the time I was done with all of that work, it was already late in the afternoon. I checked the electronic record and saw that medically, Mrs. Hamadani’s condition was virtually unchanged from the day before. There being no new Social Work or Case Management notes, I decided once again to wait before going up to the Unit. I did, however, call Dr. Broukhim but only got his voicemail; I left a message letting him know that Steve and I were now both involved and that I wanted to talk with him about what was going on.

Talking with Dr. Brouhkim

After attending a number of pre-scheduled meetings, I finally made my way to the ICU early in the afternoon. Having already done a quick review of her electronic record before going, once in the Unit, as is my usual practice, I grabbed the binder that was Mrs. Hamadani’s paper chart and began working my way through what was now nearly 3 weeks of hand-written notes, with an occasional printed electronic note interspersed. I also saw the notes Steve had told me he’d left, both hand-written, from before and then after the meeting at which he had joined Dr. Broukhim in talking with Mrs. Hamadani’s children back on the third day of Mrs. Hamadani’s hospitalization, as well as his hand-written note from two days prior, the day of the meeting which had led Mr. Zadeh to ask me to remove Steve from the case.

I also saw the various notes Dr. Brouhkim had left, and having yet to hear back from him, I again called his office. One of his Assistants answered and after giving her a quick summary of why I was calling, she patched me through to him. This was actually the first time I had ever spoken with Said Broukhim, although I had known of him for some time. And I knew of his reputation of being extremely aggressive, of even other Oncologists thinking that he pushed the boundaries. But our conversation didn’t fit the stereotype.

“Ah, Dr. Finder, I am so sorry not to have called you back sooner. I have been very busy, and with Mrs. Hamadani actually stabilizing over the past 36 hours, I knew we had some time. But I am very glad you have called. I take it you’ve seen my notes from the past 2 days?”

Indeed, I had. And unlike many others, Said Broukhim still wrote—well, actually, dictated—extensive notes, often 4 or more pages of narrative. He included detail not only of his patients’ medical condition, but also the psychosocial dynamics associated with their care. The notes for Mrs. Hamadani gave a very clear picture of all that had been going on, including his own assessment that Mrs. Hamadani was no longer a candidate for any kind of therapeutic interventions, that he had, since the beginning of this admission, been recommending a shift to a purely palliative focus, that the family seemed to understand that their mother was likely near the end of her life, but that they also were, as of yet, unwilling to consent to anything less than full code and that they continued to ask about what other options might be considered. He also referenced Steve’s notes and the conversations he and Steve had been having.

Perhaps more extraordinarily, again given his reputation, is that in reference to the meeting Steve and Annie Smith (the “lady doctor” to whom Mr. Zadeh had referred) had had with the family when Mrs. Hamadani had come back into the ICU, Dr. Broukhim explicitly wrote, “I have explained to the patient’s family that I had personally asked Dr. Moore to continue to follow the patient closely to try to provide as much support to the family as well as to try to delineate ethical issues involving the care of this terminally ill patient.” His note then continued, “I also explained to the patient’s family that the reason for ethics evaluation is not to persuade or to be abrasive to the patient’s family and it is just to provide more care for them in these trying times.”

But I expected the real focus of his question was whether I had seen his note from this morning which detailed a meeting he had had with all three of Mrs. Hamadani’s children and which had also been attended by Dr. Smith and Dr. Nadouri, the consulting nephrologist. In that note, a few things stood out.

First, there was the fact that Dr. Broukhim began by mentioning that at the beginning of the session, Mr. Zadeh spoke at some length about his interactions with Steve such that Dr. Brouhkim explicitly wrote that “we did explain to him that this meeting is not about Dr. Moore or Ethics Consultation but only about his mother.” This was then immediately followed by an overview of Drs. Brouhkim, Nadouri, and Smith’s assessments of Mrs. Hamadani’s status, the real possibility of worsening respirations developing, Dr. Smith’s opinion that if she were to be intubated there would be a good chance she’d not be able to be successfully extubated, and her poor renal function. Moreover, he wrote that both he and Dr. Nadouri would not recommend pursuing dialysis if it came to that, their basis being that “dialysis is not going to be helpful in this setting in terms of long-term goals.” He then offered that “Dr. Smith, myself, and Dr. Nadouri again discussed the fact that Mrs. Hamadani would greatly benefit from palliative measures at this point, and none of us would recommend proceeding with more aggressive measures including intubation and dialysis.”

With all of that in his note, what stood out next was that he then reported that “the family does not, at this time, wish to have me write a DNAR order, that they prefer to wait until the decision to act must be made before giving permission not to proceed to intubation.” Moreover, he reported a similar disposition regarding dialysis. And in the same breath (so to speak), he then wrote that he asked Dr. Nadouri to get a second renal consultant to take a look at Mrs. Hamadani in order to help determine if dialysis would be helpful.

After the usual listing of data, review of systems information, and so forth, Dr. Brouhkim’s note ended with this:

“As mentioned above, we had a lengthy family meeting this morning. In addition to myself, Dr. Smith, ICU attending, Dr. Nadouri, nephrology consultant, nursing staff, and case management have all spoken with the family and discussed the fact that the patient’s overall status is poor. Nonetheless, the family continues to request the patient be maintained as a full code and that dialysis be considered. We will continue to talk with the family and try to help them understand that these measures are not going to be helpful and most likely might be harmful, including shortening her life. The family fully understands these issues. All their questions have been answered. They remain at bedside and have told me that if the patient codes, at that point they will let the medical staff know if the patient should be intubated or not. Patient will remain at this point full code. I spent 8:00 am to 11:30 am this morning in the ICU providing care for Mrs. Hamadani.”

“Yes,” I thus replied, when Dr. Brouhkim asked me if I’d seen his notes form the past 2 days, “I have.” “In fact,” I continued, “I’m really intrigued by what you reported about your conversation from this morning, although that wasn’t really the impetus for my call.” I then told him about my encounter with Mr. Zaden and his sister several days prior and that I had “relieved” Steve of duty in this situation and thus would like to have a chance to sit with him and talk about what, if anything, I might be able to offer in terms of helping with this situation.

“That would be good,” he replied, “although I’d like to wait and see what Rene Spector has to say.” Dr. Spector, whom I knew was not only a nephrologist but possibly the most widely respected nephrologists in the hospital, must have been the “second nephrologist” Dr. Brouhkim had asked Dr. Nadouri to get. “He’s usually good at seeing patients within a day, so maybe we could meet tomorrow. I’m planning on being over there again in the morning; will you be free then?”

I knew my schedule was open and so told him I would be. So we agreed to meet in the ICU tomorrow morning, and we would not only talk about what had gone on so far with Mrs. Hamadani’s family, but what might be the next steps given whatever Dr. Spector might recommend. Thus our conversation came to an end.

Visiting with Mrs. Hamadani’s Daughters

As I hung up the phone after my conversation with Dr. Brouhkim, I noticed that Nadira, the daughter I had met before, was walking over toward me. Having read about this morning’s meeting, I wasn’t sure what to expect as she approached. But as she neared, there was what I would describe as a “lightness” to her face, a change from the saddened countenance I had encountered when I met her initially. I stood up to greet her.

“Hello Dr. Finder, I am glad you have come by to see how our mother is doing. Please, come and meet my sister, Farzana.” As I was now becoming accustomed with this situation, I was taken back somewhat by this. What, I wondered as we walked over toward Mrs. Hamadani’s room, had motivated her to greet me as such and then ask me to meet her sister? As we approached the room, Farzana came out to greet us, and as she began to speak, I understood.

“Dr. Finder, it is a pleasure to meet you. My brother Samir has spoken of you and he is so grateful for your help in making sure that Dr. Moore no longer is a bother to us. Thank you so much.”

She extended her hand as she spoke, which stood out as her sister, Nadira, had not. Indeed, Nadira was wearing a scarf and I was not sure if she was simply wearing a scarf or whether it was a Hijab. Farzana, on the other hand, could have walked out of one of those fashion magazines that populate physicians’ waiting rooms and beauty salons given her skinny jeans, suede boots, flowery silk blouse, scarf around her neck, vest, and array of bangles on her wrists and earrings in both ears. She also seemed to be extremely observant, for in the second of hesitation I had in shaking her hand, she remarked, “I see you are a bit unsure whether it is acceptable to take my hand. For my sister, this is true, but for me, I do not live by those rules.” As I grasped her hand in acknowledgement, I could not help but also note that her grip was firm.

I thanked both for their warm greeting, but then told them that, really, no thanks were due as I did not want to make their situation any more difficult than it was, for I had seen in Dr. Brouhkim’s notes, and those from others, that the news about their mother was, I imagined, not what they wanted to hear.

“Is your mother still alive?”, Farzana asked, looking intently and directly at me.

“Yes, she is, as is my father,” I replied.

“Then you undoubtedly know,” she continued, “how special it is to still have a mother with whom you can interact. As I know my brother told you, we have been blessed for the past 3 years to have been given a gift of these extra years to have our mother with us. None of us thought she would live this long, and Nadira and I have spent much of this time making sure that our mother is taken care of, that we do for her what she did for us, for all of us, even including our father, in the past. Although I have lived here in the United States for almost 30 years, I still hold fast to some of the values that come from our homeland. And respecting and caring for one’s parents is high on the list. Unfortunately,” and here she began to trail off, “many here do not share this belief.”

Nadira, now standing next to her mother’s bed, was holding her mother’s hand in her’s and gently stroking it. At the same time, she had her body slightly turned so that she was facing me and Farzana, and as Farzana was speaking, she nodded her head in agreement.

“Is it OK if I ask you some questions about your family?”, I asked, wanting to be respectful of their space but also making the choice to take advantage of what seemed to be an openness toward me that I wasn’t sure existed. But if it did, I did not want to miss the opportunity it provided to learn more from Farzana and Nadira.

“Of course, Dr. Finder,” Farzana replied, again with the spark with which she had initially greeted me and then spoken.

Thus began what turned out to be a 45 min conversation with Nadira and Farzana. I learned that Farzana had initially come to the US in the mid-70s to go to college, and like many international students, decided to stay, attracted by the opportunities here. After the Shah fell in 1979, she had limited communication with her family until Samir had been granted permission to leave in the late 1980s, and then in the mid-90s, Nadira and their parents had come as well.

I also was told of their father’s slow descent into dementia and how for the past few years, starting before their mother’s cancer and continuing even until now, they had helped to take care of him. It was in this conversation that I thus learned that their father had been in a rehab facility for several weeks and was scheduled to come home any day now, and that they had not told him of their mother’s hospitalization and so were worried what was going to happen when he was discharged and they brought him home but his wife was not there.

As an indirect learning, I saw that Farzana also seemed a bit dismissive of her younger sister, interrupting her on the few occasions when she tried to interject or add some detail to the tale Farzana was telling. Nadira, on the other hand, took this in stride. Both sisters, nonetheless, spoke only with a positive light about their brother, Samir, the youngest of the three. They expressed their concern, moreover, that unlike the sisters, both of whom, it turned out, were married and had children, Samir had yet to marry for he had not found a woman whom he believed his parents would accept. And since his mother’s cancer was discovered, he had turned most of his energies, when not working as a salesman, toward making sure her care and her medical needs were met.

In short, I was presented a picture of a close-knit family in terms of there being a shared sense of commitment toward each other even as their lifestyles and ways of living differed (for instance, the religiosity of Nadira was more in line with what Farzana presented as her parent’s beliefs, but she was nothing of the sort, and Samir was more like her than Nadira although he would occasional go to the mosque, especially during times when his mother was most ill).

The fact that I was willing to stand in the doorway of their mother’s room, moreover, and listen to what they had to say did not go unnoticed. As our conversation wound down, both Farzana and Nadira remarked how grateful they were that I had shown an interest in their family and their experiences, and perhaps more importantly, that I had not told them how sick their mother was and how it was unlikely that additional intervention would make a difference to what, they didn’t say explicitly but clearly hinted at in what they did say, was to come next, and soon at that.

We thus parted, and I left the Unit wondering whether we sometimes insist too strongly on having families speak directly about their loved one’s deaths.

Meeting with Dr. Broukhim

The next morning, as we had agreed, I went to the ICU and met with Dr. Broukhim, and again contra to his reputation, he not only seemed to be pleased to have the chance to talk with me, but he was nothing short of explicit that he believed that the best thing for Mrs. Hamadani at this point was to shift to comfort only care.

“I think you know that I have a reputation for being very aggressive with my patients,” he said several times, “and maybe it is more than others,” he continued. “But when it comes to the point that I know I have pursued everything that might give them more life, I am also very blunt with them, and they know that if I say we are near the end, then it is true.”

While these words could come across as arrogant and perhaps self-aggrandizing, they didn’t. Rather, they were spoken each time during our conversation with a sense of care, that he would do whatever he could to help his patients as long as it would help them accomplish their goals and fit with their expectations. There was even a somewhat prominent degree of humility in his presentation that was not of the kind that one can fake or put on.

Perhaps more importantly, he was genuinely distressed over what was happening with both Mrs. Hamadani, as his patient, and with her children, as the ones he knew his patient cared about most, and thus for whom he too was deeply concerned. As I began to see, although it was not stated explicitly, part of what he was looking for in talking with me was reassurance that he was helping Mrs. Hamadani’s children come to accept that he had few to no options left to provide for their mother.

More directly, he told me that late yesterday Dr. Spector had come by and decided that dialysis might be useful. While Dr. Broukhim did not think it necessary, he accepted Dr. Spector’s assessment. In light of yesterday’s conversation, this was not what I had expected.

Then the zinger: “Do you think this reasonable?” he asked.

‘What a question,’ I thought, given all that might be entailed in coming to any accurate sense of ‘reasonable.’ “Well, obviously, I must trust Dr. Spector here in terms of his judgment about the kidney and how dialysis fits into Mrs. Hamadani’s current picture. I also know from what you’ve been saying in your notes and what the other consultants you’ve had weigh in, that in the big picture, dialysis won’t change the ultimate outcome. Then there’s the fact that this family seems to want to try whatever might hold out some sense of hopefulness for their mother to recover, even if only somewhat, and that’s actually what she’s been doing too for these past few years.”

“I know there are a lot of folks,” I continued, “who wouldn’t hesitate a second and say that dialysis in this setting is completely uncalled for, that even offering it is problematic because, that it’s a bad use of a limited resource and is a prime example of why our healthcare system is in the state it’s in and why we need reform. For me, the details in the particular are the key, and it may well be that a few rounds of dialysis could help, give her a few more days to get over this hump. A lot turns on what the goal is.”

“Do you know what Dr. Spector is after?” I asked. Broukhim replied that the thinking was that in the short-term, dialysis could help with the volume overload, hypernatremia and metabolic acidosis, and if the BUN could be brought down, there was a chance that her mental status might improve. “He thinks she may have some degree of uremic encephalopathy so this could help.” He then turned to Spector’s note from last night.

“He was pretty clear that, like you said, a lot turns on the goals; see.” And with that he pointed to the end of Spector’s note which read, in part,

“Renal replacement therapy is clearly indicated at the present time. However, this decision should be carefully considered with regards to both short-term and long-term expectations in medical outcomes. The patient may not tolerate due to hemodynamic instability. Unlikely to recover renal function, but will assist in dropping BUN, possibly improving mental status. I have discussed with patient’s son and daughter, both eager to proceed if chance for improvement. I suggest they consider a short trial (i.e., 3 or 4 sessions) with the clear understanding that if her general condition fails to improve substantially, dialysis will be discontinued. They will discuss with other family before proceeding.”

“I think with all that they’ve been through,” Broukhim now said, “it’s not unreasonable to see if we can wake her up and give them a chance to have a little bit a final time together. She’s been a real fighter all along, and they’ve been so involved in her care, I think I owe them this.”

For the fourth time in the 20 min we’d been talking, Broukhim’s cell phone rang, he looked at the number, and then silenced the ringer. Then he said, “What I’d like to do is to give her a few more days and then have another family meeting with all three of the children and you. Of course, this is assuming that she remains stable between now and then. Does that sound OK with you?”

It was, and I said so. He then thanked me and as his cell phone began to ring again, this time he answered.

Another Few Days Interlude

Over the next few days, Mrs. Hamadani received several more sessions of dialysis and her mental status did improve somewhat, and there were points when she was purposeful. Removing the excess fluid also seemed to improve her respiratory function somewhat, although she continued to require Bipap most of the time; on occasions, her family took the mask off and her sats would slowly drift downward toward 90%, at which point they’d put it back on. The other main issue during this time was that her platelet count was dangerously low, down in the 10,000 range, and it was only with transfusion that they were able to see any improvement.

Several times during these days I stopped by and stuck my head in to say “Hello” to whomever was there, mostly Farzana and Nadira, although on two occasions Mr. Zadeh was also present. My aim in doing so was simply to keep tabs, much as Steve had done during prior hospitalizations. But unlike then, and unlike during the earlier part of this hospitalization, I did not inquire about whether they had thought more about CPR and DNAR or if there had been discussions of stopping the dialysis. Rather, I kept my focus on how they were holding up, especially the sisters who also had families for which they had responsibilities. I also asked about their father and the now unfolding plans as he was about to be discharged.

None of the conversations I had were as long as either of the priors ones, and for all of the initial warmth and openness that had been displayed when I first spoke with Farzana, these were much more truncated. I would not characterize the interactions as unfriendly or cold, nothing like that. They were always polite and gracious, but there was never a sense of their wanting to have any sort of sustain discussion. Their focus was clearly on their mother and anything that redirected their attention was of limited value.

During this time I also spoke with a variety of other care providers—nurses, respiratory therapists, the Unit social worker, and, of course, the physicians. With almost all of these conversations, there was little doubt about how these providers were experiencing Mrs. Hamadani’s children. As Dr. Broukhim put it to me once when I saw him, the medical and nursing staffs were very “ticked off” by what he and Dr. Spector were “doing to” Mrs. Hamadani, and there was a resentment toward the family. Some of the staff were pointing fingers at other members of the staff, especially those who had developed a “give them what they want” approach toward the family whenever they requested extra attention. For instance, the fact that they were removing the Bipap mask themselves and questioning every intervention or interaction, be it drawing blood, changing tube feeds, or getting Xrays of her lungs. Dr. Spector’s continued willingness to offer dialysis, of course, was the focus of most of the negative concerns surrounding Mrs. Hamadani’s situation, and this was despite the fact that she was now slightly improved.

In talking with Dr. Broukhim, he was clear that he did not believe the improved mental status and stable hemodynamics that were attributed to the dialysis would last. Still, he was willing to defer to Dr. Spector. When I spoke with Spector, he reiterated what he’d written in his note: he’d reassess after 3–4 sessions of dialysis had been completed.

On the third dialysis day, I did have a somewhat longer conversation with Mr. Zadeh, which turned out to be significant for this reason: away from his sisters (I ran into him as he was leaving, and I was entering, the Unit, so we went and sat in one of the Meditation Rooms annexed to the family waiting area), he was quite explicit about his understanding of what was going on with his mother.

“You know, Dr. Finder, it has been a great blessing to have had these extra years with my mother, and I am deeply grateful to Dr. Broukhim for all that he has done. But I always knew that someday it would eventually come to end, that I will have to say goodbye to my mother. It is an awful feeling to know that, and even now, I still shutter at the thought of it.” As he spoke this, he was slightly hunched forward, his hands crossed on his lap, his head slightly downcast. “I never think these thoughts when I am with my sisters for I must be strong with them. Our father, he has not been the strength in our family for some time, my mother was. And maybe she always has been, I do not know. But my sisters are devoted to her and have cared for her and have sacrificed for her.” And then he just sort of stopped talking, and despite his large size and somewhat imposing figure, I was struck, really struck, by his vulnerability.

“Your parents would be very proud of you and your sisters for all that you have done, all that you continue to do, for them,” I said, not sure if this was appropriate or if, rather, it was best to share the silence with him. I thus paused in the stillness of our sitting there, in the room.

And then it was gone.

“I have an appointment to which I must go,” he said while starting to stand up. “Thank you for talking with me, Dr. Finder, I am grateful.” We’d barely had a conversation but for a few words, really.

“I think Dr. Broukhim wants to get together with you and your sisters and me in a day or so; has he mentioned that to you?” I asked somewhat awkwardly since, if Broukhim hadn’t, I may have erred.

“Yes, he has mentioned that. I will see you then.”

And with that, Mr. Zadeh continued on his way. I went back into the Unit to see if there was anything new. In Broukhim’s newest note I saw that he’d written that he and I were to meet with the family at 7:30 am the day after tomorrow.

The Family Meeting

I usually arrive in my office around 7:00 am, check email and get myself organized for the day. On this morning, I arrived even earlier so that I could get to the Unit a little bit before 7:30; it was 7:25 when I arrived there and Mr. Zadeh and his sisters were all in their mother’s room. I sat down at the nursing station and waited for Dr. Broukhim. While waiting I pulled up Mrs. Hamdani’s electronic record and read Dr. Teharani’s, the consulting pulmonologist, note from yesterday. In it he mentioned that “upon examination of the patient, the patient is in agonal respirations,” the result, it was determined, of the new Bipap masks not fitting well and hence not providing the necessary support; this was corrected and her status improved somewhat. He also stated that he discussed the possibility of intubation versus Bipap and that the daughter with whom he spoke—he did not indicate whether it was Farzana or Nadina—“implied that they are making decisions favoring not intubating the patient.”

More interestingly, his noted continued, he had “extended my discussion to include intubation for respiratory failure even on Bipap which may be the case soon,” and in this context, “the daughter was hesitant to make a decision and instead asked that serial blood gases be performed over night to assess the patient’s condition” and that it would be “based on the results, the family would decide whether to intubate or not.” He then noted that his interaction with the daughter “was pleasant and to the point” and that “her sister made a point to give a warm hello prior to leaving the room which was just prior to me entering.”

And then the kicker:

“Due to my interaction with the patient’s son the day before, especially his aggressive, abrasive and threatening tone and body language, complicated by his lack of faith in my recommendations, I gave the daughter a list of all active pulmonologists on the medical staff and offered to continue to treat the patient until they could find a replacement, at which time I will sign off. The daughter was grateful.”

Obviously I’d missed something. But before I could pursue it further, Dr. Broukhim was standing next to me and he was making motions towards the family to come out of the room. I logged-off.

“Should we talk here?”, Broukhim asked me as Mrs. Hamadani’s three children approached the nurses station where I was now standing.

“No, it might be better to go and sit in one of the Meditation Rooms in the family waiting area,” I suggested, and together, the five of us walked out of the Unit and headed to the Meditation Room in which I had previously briefly spoken with Mr. Zadeh.

We went into the room and sat down, the family sitting on one side, Dr. Broukhim and I on the other. Given the set up, I wasn’t sure if I was there to help Dr. Broukhim or to facilitate a conversation, or both, or just to bear witness, so to speak. Accordingly, I waited to see what came next rather than assume that I was to begin this conversation.

It was, I discovered, the right choice, for Dr. Broukhim began without hesitation.

“You all three know that I adore your mother and I am honored to have been able to serve as her doctor these past few years. And I believe I have been able to help her, and I thank you for the opportunity to do so and to get to know you and your family in the process.”

Already I could sense that this was a different kind of conversation than what I was used to, as Dr. Broukhim went on, using words such as “praise” and “respect” and “devotion” in reference to his interactions with Mrs. Hamadani and her three children who now sat across from us. And during this, they sat politely, one of them occasionally bowing their head slightly, all with hands gently folded on their laps. And when there was a pause, Mr. Zadeh began to thank Dr. Broukhim for all that he had done, and he expressed gratitude on behalf of his mother and his sisters. And as he spoke of his own appreciation for all that Dr. Broukhim had done, and the praise they all had for him, at times he held his hands to his heart and his eyes became slightly teary. At different points, both Farzana and Nadira shook their heads in agreement to what their brother was saying. For my part, I sat quietly and listened as, after this preface of what would be the conversation, Dr. Broukhim spoke once again.

He began to summarize all that had gone on with Mrs. Hamadani, beginning with his initial involvement as her oncologist. The prior 3 years worth of history were outlined fairly quickly, and so it was these past few weeks that became the real focus of his summary. Organ by organ, system by system, he presented all that was now failing: liver, lungs, kidneys, heart, brain.

“Her liver is now in the process of shutting down,” he began, “and her lungs are unable to provide the necessary oxygen that keeps the body able to function. She’s been on Bipap for over a week now, and typically, if a patient does not respond within that time-frame, we either elect to intubate or to withdraw care.”

I cringed as he said “withdraw care” but now was not the time to suggest a different way of speaking.

“As you know, I had Dr. Spector review her renal situation which led to her having the several rounds of dialysis, and initially it seemed to make a difference. But after yesterday, he has decided that she is too sick for additional rounds, that whatever improvement it might potentially offer is far offset by the risks that her blood pressure would fall and we would not be able to maintain it.”

“And in that regard, as for her heart, she is trying to compensate by working harder, but she can’t keep up and we now have had to start her on medications to keep her blood pressure stable.” This was a change from 2 days prior, but her children, having been in her room non-stop, already knew this, so it was only for me that this was news. “Although we’re holding ground right now, if her blood pressure drops, we can increase these medications a little, but then there will be nothing more to do.”

“And finally, with the shutting down of her liver and kidneys, her brain is now being crippled by the poisons these organs usually eliminate. When we take all of these together, and put it on top of her cancer, I am afraid that her time is very limited, possibly only days, weeks at best.”

With these words, the picture he painted was dark indeed. But after having outlined all of this, he immediately shifted his focus, telling them that he simply wanted to ensure that they understood what was going on with their mother, not to change their mind about what to do, not to get them to say that they should withhold additional interventions or even withdraw any of the support currently being provided. “I know this is very difficult for you, and I want to make sure that you are fully in tune with what is happening so that you all can have the proper expectations for what is to come.” With only a slight pause, he then stated that he was doing everything that he could to make sure that their mother was comfortable and not suffering, that above all else, “she has been such a lovely person and I do not want to do anything that will make her suffer.”

This time there was a longer pause, and it was clear that now was the time for the family to ask whatever questions they had. Somewhat surprisingly, there were no questions. Rather, first Mr. Zadeh and then Farzana acknowledged their understanding of all that Dr. Broukhim had presented. Moreover, they thanked him for not only what he had done over the past few weeks, but for all of the care he had provided their mother during the years. Their tone was deeply respectful and there was not a hint of any sort of disagreement or discrepancy, difference or disconnect. As they spoke, I again harkened back to when Mr. Zadeh had asked me to stop Steve from seeing his mother: was this all as it seemed or was there manipulation occurring? After all, I still had Dr. Teharani’s comments about how Mr. Zadeh had responded to him just 2 days ago and his own decision to remove himself from Mrs. Hamadani’s case echoing in my thoughts.

And then, there it was:

“As you know, Dr. Broukhim, our mother has always been a fighter, a pillar of strength and determination and an inspiration for all of us, yes Farzana and Nadira, do you agree?” They nodded to their brother, and Nadira wiped her eyes. “And that is why, Dr. Broukhim, that our mother knew you were the right doctor for her because you too are a fighter. I remember the first day we came to your office and you told us about all the other patients in your waiting room, patients on whom others had given up but for whom you did not, and would not as long as there was hope.” Mr. Zadeh’s voice had that timbre I remembered as well, and with his size, the tone could easily come across as somewhat intimidating.

“That is why my sisters and I want you to continue everything that you are doing for our mother. And when the time comes that a decision needs to be made as to whether to do CPR or put her on a ventilator because she can no longer breathe, we will make our decision at that time, taking what the doctors and nurses tell us then.”

Interrupting him, Dr. Broukhim acknowledged that Mrs. Hamadani was as Mr. Zadeh had stated and had strong views about fighting her cancer and that he wanted to be certain they understood that if they wished their mother to be coded then he would support them. But he did think it important for them to know that, “it is my professional recommendation that you not allow your mother to be intubated or cardioverted or to receive chest compressions as these interventions will not change the inevitability that awaits her, but they will likely cause her harm, which I do not want and I know you do not want.”

Again, Mr. Zadeh spoke: “I think we all understand exactly what you are telling us, and I, and I believe my sisters too, appreciate the care and concern you show for our mother such that those are your recommendations. That is why, Dr. Broukhim, that we request from this point forward, we talk with no other doctors except you.”

At this, Dr. Broukhim turned to me, literally, turned to face me, although he said nothing. It was as if he was now looking to me to help him, to decide whether this kind of arrangement was something to which he ought to agree. At least, that’s how it struck me as he turned and looked at me as Mr. Zadeh concluded his comments.

Aware of the tension that had been developing between the family and other care providers, and given the fact that Dr. Broukhim had asked me to join him in this conversation and yet had not really invited me to participate in any substantive way until now, I wasn’t quite sure what he now had in mind in turning to me. So I used this moment of redirection to restate all that I had heard over the course of their conversation, framing my remarks with the point that it was only by a kind of accident that I had become involved in Mrs. Hamadani’s care, and as such, when it came down to it, I knew very little about all that was involved.

“But,” I continued, “I do know this: you’ve got to trust one another since you’re going to continue going through this together, one way or another. And I don’t think I’m speaking out of turn in saying that there’s been some, eh, lapse of trust with other physicians and care providers, so anything that can re-establish that trust is really important.”

As I paused for just a second, I did a quick scan of the others to see if my use of trust as a theme was making any sense, and it seemed to be. And as I was about to continue, I suddenly found myself becoming once again aware of earlier conversations, only this time it was of what I had learned from Steve about his participation with Broukhim in that very first family meeting in which Steve had stepped into the breach when it looked as though all were on the same page, and what he said there had become the locus of their dissatisfaction with him. I decided I’d take the risk.

“When you have a really sick patient and a lot of different providers involved, there’s always the difficulty of making sure that everyone is on the same page, so to speak, that what one person says is not misunderstood or confused by what others say or mean or intend. So I think if Dr. Broukhim is willing to play that role and have all the communication about what’s going to be done for your mother flow through him, then that can work fine. But underlying this is the real issue, which is making sure that, as Dr. Broukhim has already said, you understand what’s going on and that your expectations match, because the real problems are caused when we’re not prepared for what’s staring us in the face.”

It all just came out and I wasn’t sure if that was the right tact to take or not. But it became immediately clear that it was.

“You know, Dr. Finder,” said Mr. Zadeh, “I think you are right. But the problem here is that everyone keeps telling me and my sisters all these bad things about what is going to happen to our mother as if we do not understand. But we do understand, we are not uneducated people. But is it too much to ask to please stop preaching about what is going to happen to our mother? We understand, we know, we get it!” His voice was now raised, and Farzana reached over as if to calm him, but he was in the grip of the moment, of release, perhaps.

“I do not want my mother to suffer, no one should ever want their mother to suffer. I do not need to hear ‘we do not want your mother to suffer.’ What I want is for my mother to be taken care of, and when the time comes to make a decision, my sisters and I will decide, and we will do what is best for our mother. This is not about me or you or Dr. Broukhim or anyone else. This is about my mother. Enough already, I understand all that you tell me, I understand all that Dr. Broukhim tells me, I just request otherwise. The doctors need to take care of my mother, the nurses need to do what they are supposed to do, and we, as the family, we will make the decisions that we need to make. OK?”

He paused and then added, “Please Dr. Finder, I do not wish to cause problems, and I apologize for raising my voice. But I do not ant to talk about this anymore and I do not want to talk with anyone else but Dr. Broukhim.”

The End

How does one end a meeting such as this? There is no set way, nor, I believe, should there be. We often proceed as if endings need to be smooth and unitary, all the loose strings tied up together into an easily digestible resolution. But why should that be when the very context, and content, of such meetings concern a kind of coming apart, a dissolution, an undoing of a moment that has lasted possibly 83 years?

Mrs. Hamadani died just a few hours after this meeting. Her blood pressure bottomed out, and as Mr. Zadeh had requested, he and his sisters were asked, as their mother’s heart rate went erratic and breathing became even more irregular, what they wanted to be done. And without hesitation, without dramatics, without conflict, they stated unanimously that they wanted to make sure their mother was not suffering, and they wanted to be alone with her and she passed from here to wherever she went, if any place at all.