Patient M is a 78-year-old Greek man with a bad heart. According to the chart, his previous hospitalization for congestive heart failure a year ago ended when he left against medical advice and flew to Greece to spend time with family. He returned to the United States last month and was talked into coming to the office by his son only after he became dyspneic at rest. My practice partner Bob thought M was in early heart failure and after much histrionics convinced him to go to the emergency room. It was a good call, since within an hour of arrival at the hospital M went into florid pulmonary edema and was intubated.
When I saw him for the first time the next morning in the cardiac care unit (CCU), the cardiology team estimated his ejection fraction at only 20%. He had been trying repeatedly to pull out his endotracheal tube, so an intravenous sedative infusion had rendered him obligingly snowed. Although my resident and I took turns listening to his chest and shouting in his ear, I wondered how much English M understood. “Not much,” his son informed me when I called to make sure the family knew how critical the situation was. The son also offered his opinion that “Dad really had wanted to go the hospital to get his heart stronger.” That sounded funny on the basis of what I had heard of the previous afternoon’s struggle. I took the son’s word that his father would wish all further treatment, should things deteriorate.
M’s heart didn’t deteriorate but responded amazingly well to the various medications the cardiology wizards manipulated. Isoenzymes were negative for myocardial infarction, and his heart was seemingly stronger than anyone suspected. So was he, as the pulling behaviors continued. The CCU team kept him restrained until he was extubated and transferred out of the unit to our service. Up on the floor, each intravenous line lasted only approximately 3 hours before M pulled it out; the oxygen cannula stayed on only while someone was in the room. M’s appetite was great, not just for the food his son brought on nightly visits but even the for hospital fare, so I had the residents stop the intravenous tubes. Likewise, room air oxygenation was adequate, so I stopped getting frustrated by his not wearing an oxygen mask. Getting the nursing staff to stop restraining M was more difficult though, especially after he made quite a scene resisting getting on a transport stretcher to go for a chest radiograph. A Greek-speaking aide finally found out that he thought he was being taken for an operation: Why else wouldn’t he be allowed to walk? The physical therapist did think he walked pretty well, though M reportedly became upset at having to sit in a wheelchair to get back and forth to physical therapy.
I had some periodic phone contacts with the son following our initial intensive care unit conversation but wanted to set up a meeting in person. That evening M just beamed, seeing the 2 of us standing at his bedside, and launched into a long story—“something about how Dad wishes I would have become a doctor just like you” was all his son told me 20 minutes into the epic. It seemed as if M wanted me to just stand there and listen to some detailed, obviously profound story that he must know I couldn’t possibly understand. I finally interrupted him and got through my usual review of discharge and medication instructions that the son dutifully translated for his father. After pausing from my epic, I wondered how much M remembered of how sick he was. A too-prompt reply came from the son: “Oh, he can’t remember much at all about that.” I said I needed to know if M would want to be treated the same way should his heart fail again—the intubation, the restraints, the sedation, the possible recussitation. The son looked at me and said, “I won’t ask him that, Doc. You all did wonderful for my father and I know at some point his heart will fail, but look at him now. How could we not try to do it again?” Nothing else I said that night got translated.
Perhaps I should have used one of the medical translation services instead of relying on M’s son that evening. Perhaps I should have used a translator alone with M to get an idea of the advance planning before meeting with his son. But I doubt that any translator, no matter how skilled, could describe and define the nature of that relationship between M and his son that lies at the heart of surrogate decision making, regardless of the language involved.