Richard Mabry: Diagnosis Death

The hollow feeling in Elena's stomach intensified.

"I've been in private practice for fifteen years, going it alone. There aren't many of us left in solo situations, but I've held out. I've managed to get other doctors in various groups to share call with me, but lately that's been somewhere between difficult and impossible."

"I know. That's why you wanted to bring me into the practice," Elena said.

"True, but that's changed. The Lincoln Clinic has approached me to join their family practice section. Actually, they want me to head it. They've made me a great offer. Not just the money, although that's good. The whole package seems tailor-made for me. I'll be supervising six other doctors, and I'll be exempt from night call. A great retirement plan and benefits." Helen looked down at the tabletop. "I couldn't turn it down."

Elena's mind scrambled for a solution. The ship was sinking, and she grabbed for something to keep her afloat. "So why don't I take over your practice? I can buy you out. I mean, I won't have the money right way, but I can pay you over several years. It'll be sort of like an annuity for you."

Helen was already shaking her head. "No, one part of the deal was that I bring my patients with me. The clinic will hire both my receptionist and nurse, and give them a good package as well. They'll even buy my equipment from me. I've already terminated the office lease. I'm moving out in ninety days."

Elena forced back the tears she felt forming. "Helen, do you realize what this does to me?"

"I know. I just-"

"No." Elena worked to keep her voice level. "You don't know. You don't know how I've struggled to get through my residency after Mark's death. You have no idea what it meant to me to have a practice waiting for me. No need to lease space, to remodel and buy equipment. No waiting to build up a practice. There'd be a guaranteed income and a chance to pay off a mountain of debt."

"Elena-"

Elena shook her head. "I finish my residency in less than a month. Thirty days! Now you've pulled the rug out from under me. I have four weeks to find a way to do the only thing I know how to do-practice medicine." She turned her back to Helen, thinking that Helen had done the same thing to her. "No, I realize this is good for you, but I don't think you really know the effect it has on me."

"Elena, I had to do this. Once you get over the shock, you'll think about it and agree. But listen, I'm not going to leave you hanging."

Elena turned back to face the woman who'd been her mentor, the friend who was now betraying her. "What do you mean?"

"The clinic gave me a very short deadline to accept or reject their offer. I only made my final decision this weekend. But the second call I made, after the one to the clinic administrator, was to your chair, Dr. Amy Gross. She and I are both putting out feelers for a place you can practice." Helen reached across the table and patted Elena's shoulder. "We know how hard this past three months have been on you. We worry about you. And believe me, we won't abandon you now. God has something out there for you. Trust Him."

Elena drained the last of the coffee from her cup. When she set it down, she knocked her fork off the table. The dull clank of silverware on vinyl floor was barely audible over the low hum of voices that filled the cafeteria. "Trust God? I don't think so. I trusted Him when Mark lay there fighting for his life, but it didn't seem to do any good."

"I know. But He's still in control."

Elena shook her head, while one more hobgoblin joined those already dancing in her brain.

Elena hesitated in the doorway. She felt her adrenaline titer rise in response to the most ancient of reflexes: fight or flight. Unfortunately, neither was an option right now. "You wanted to see me?"

Dr. Amy Gross, chair of the Department of Family Practice at Southwestern Medical Center, sat behind a desk devoid of papers except for a thick file barely contained by a slightly ragged manila cover. To her right, Dr. Bruce Matney, chair of the Department of Neurosurgery, adjusted his white lab coat to better cover his gray-green surgical scrubs.

Dr. Gross waited until Elena settled into the single chair centered in front of the desk. "I appreciate your coming here today."

As though I had a choice. When the chairwoman's secretary calls residents and asks them to be in her office in an hour, it's pretty much a command performance.

"We know that the wound from Mark's death is still tender," Gross continued.

Elena glanced at Dr. Matney and saw the frown that crossed his face. He'd liked Mark, and his inability to save her husband after his intracranial bleeding episode probably still ate at the neurosurgeon.

Gross tapped the file. "But there's something here we need to discuss with you." She flipped to a spot marked by a yellow Post-It note. "Dr. Matney was in Medical Records yesterday to dictate summaries and sign charts. They'd sent Mark's chart back to him for a signature on something he'd missed, and he noticed this. It's an order he didn't write."

No problem there. Lots of doctors wrote orders-residents, staff taking call for a colleague. Stay quiet, Elena.

Gross turned the chart to face Elena. "Tell us what you see here."

Elena leaned forward and read the words she already knew were at the heart of this matter. "DNR."

"And the signature?"

"It's mine."

Gross frowned. "Elena, we all know how difficult it was for you as a physician to let someone else direct your husband's care. And we recognize that the decision not to resuscitate your husband was yours to make. You told Dr. Matney repeatedly that you couldn't bring yourself to withdraw life support. Then, on the same day that a 'do not resuscitate' order appeared on the chart-not written by the attending physician-your husband's respirator was disconnected without the knowledge or participation of any of the staff." She paused like Perry Mason addressing a particularly reluctant witness. "Can you explain that?"

Two pairs of eyes focused like lasers on her. What could she say? Best to keep it simple. "I'd held off as long as I could, but I finally accepted that we couldn't keep Mark on life support any longer. Dr. Matney, you were in surgery, and I was afraid that if I didn't follow through right then I'd change my mind. Writing the order was sort of symbolic for me."

Matney's voice was like polished steel. "And did you turn off Mark's respirator?"

The silence seemed to stretch on endlessly. Elena's shoulders sagged. She looked down at the floor. "I don't know." She swallowed hard. "I honestly can't recall."

No one seemed to know how to respond to that. Finally, Gross said, "I can understand. It was a very traumatic experience, and we often tend to block out those memories." She looked at Matney, then back at Elena. "I believe we can overlook your writing that order, although you recognize it was a serious breach of both protocol and ethics. And, if you did take matters into your own hands to end Mark's suffering, we can understand that as well. But we have to be certain that nothing like this will ever happen again. You can't let this carry over to affect other patients under your care."

Elena looked up at the two doctors with what she hoped was the right expression of contrition. "You have my assurance."

Matney scraped his chair backward and rose. He favored the two women with a single nod and left the room as though marching off to save the world. Gross leaned across the desk and extended her hand. The cold, formal voice she'd used moments before gave way to the kindly tone of an older sister. "Elena, my door is always open. Come and talk with me anytime."

Even as Elena expressed her appreciation, she knew that no help would come from talking with Amy Gross or anyone else. Nothing would help.