A Rotation in Ethics

A cheery pumpkin sticker decorates the glass wall of the room recently vacated in the critical care unit. The bustle in the corridor and hum from adjacent rooms contrast with the stillness on the other side of the glass: an empty bed made up with neat, white sheets, medical equipment pushed back from the bed—monitors, hanging bottles, contraptions that keep sick people going—all of the machinery now idle and quiet, no longer buzzing and blinking with the vital indicators of life. The lights in the room are turned off, but slivers of sunshine seep through the window blinds, a flickering reminder of the life that recently slipped from this small room.

Terrence Horan learned about the cancer patient on the day he began his student internship at O’Connor Hospital in San Jose. The hospital had pursued every possible medical avenue for the young father who deteriorated day after day, consumed by his voracious disease, attached to a respirator and heavily sedated except during brief moments while his anguished wife visited.

As Horan familiarized himself with the hospital that first day, he observed the nursing staff caring for this patient and learned that the man’s prognosis was bleak. If not sedated, he was wracked with pain. Without the respirator, his lungs would not breathe. As in many terminal cases, the medical staff and social workers were working to gently help relatives accept that this man was not going to rebound.

“I realized that finally the family was ready to let go…[It was] a time for the family to get used to the fact that he’s not going to be here.”

—Terrence Horan, SCU biology major

Terrence Horan learned about the cancer patient on the day he began his student internship at O’Connor Hospital in San Jose. The hospital had pursued every possible medical avenue for the young father who deteriorated day after day, consumed by his voracious disease, attached to a respirator and heavily sedated except during brief moments while his anguished wife visited.

As Horan familiarized himself with the hospital that first day, he observed the nursing staff caring for this patient and learned that the man’s prognosis was bleak. If not sedated, he was wracked with pain. Without the respirator his lungs would not breathe. As in many terminal cases, the medical staff and social workers were working to gently help relatives accept that this man was not going to rebound.

Over the next couple of weeks, Horan continued to visit the hospital as an intern with Santa Clara University ’s applied ethics program. On each visit, he walked by the man’s room. Each time, Horan took note: the patient was still there, fading but still a presence for his family and the hospital workers who took care of him. Then came the day that Horan glanced into the room and saw only the empty bed, the lights shut off, the machinery idle. The man’s struggle was over. “I realized that finally the family was ready to let go,” recalls Horan, a biology major from Sacramento. He realized something else: that the man’s last days on life support were not a time when medicine held out hope that he would rally, but rather “a time for the family to get used to the fact that he’s not going to be here.”

It was the kind of searing experience that Horan and 15 fellow Santa Clara undergraduates encounter in various ways during the year-long internship at O’Connor. As observers, they find themselves witnessing life-and-death struggles, as well as every-day medical and bureaucratic challenges that face health care professionals on the job. The students visit the hospital twice weekly, hosted by O’Connor in a partnership with the University’s Markkula Center for Applied Ethics.

When is enough enough?

The four-year-old program aims to expose students to the ethics side of a medical career, an area becoming ever more challenging as science and technology propel medicine to levels of complexity unimaginable when O’Connor was founded in 1889.

The interns shadow nurses and physicians who navigate this changing industry, caring for patients, making medical decisions and interacting with families, social workers, and the chaplain’s staff.

The goal is to show students how medicine is practiced “in context…and then to overlay that with the ethical considerations that just bubble up everywhere,” says the Ethics Center’s Director of Biotechnology and Health Care Ethics, Margaret McLean, who developed the internship program.

“The medical issues are pretty clear,” she says. But beyond medicine, a broader landscape was emerging 10 years ago when McLean spearheaded formation of O’Connor’s own Applied Ethics Center to address ethical problems in the hospital and help advise patients, families and medical workers. Ethical issues will only become more prominent as medicine and biotechnology move ahead, she predicted.

“A lot of it has to do with end-of-life decision making,” McLean continues. “Medicine can do a lot to keep people alive, but it can’t necessarily give them back their life.

There’s an ethical chasm in between those two things, and how do you bridge that? When do we change the direction of our caring from trying to save your life to allowing the best possible ending of life? Medicine can do an awful lot for you. It can also do a lot to you. The challenge is: When is enough enough? Who makes that decision? How do we support aging, dying persons? How do we support their families? How do we take care of the caregivers who are being asked to shoulder more and more of the burden?”

Not just the healing process

Both the student program and O’Connor’s Applied Ethics Center underscore the hospital’s role in confronting issues such as prolonging life, diverse families and cultures, patients who have no relatives or close friends, and insurance-mandated parameters on services. The students meet in class every other week to discuss their hospital experiences and grapple with the broader questions.

One student might observe an O’Connor nurse and patient discussing “advance directive” decisions on how far the hospital should go to keep the patient alive when the body gives out. Another might watch a physician’s frustrated efforts to locate a specialist who accepts MediCal patients. Yet another intern might witness communication difficulties with a non-English speaking patient, or the surrender of a drug-addicted mother’s newborn baby to county officials, or the conflict between family members over treatment of an elderly relative no longer competent to make her own critical decisions. One student saw a mother’s dilemma when she was told to keep her contagious child away from day care, knowing she would lose her job if she stayed home with the child.

The observer’s role is not necessarily a distant one. When former student intern Maliheh Movassat witnessed a cancer patient’s death, she was pulled into a gripping tableau. The patient was comatose and nurses revived him once while waiting for his family to arrive. “Although he was in a coma, the nurses talked to him, encouraging him to hold on until his family could get there. I even found myself talking to him, saying, ‘Hold on. They’re almost here,’” the student later wrote. The family did arrive and the man died almost at once. “But it was not terrible or horrible, as death is so often pictured. In fact, it was as if a blanket of peace had been placed over him and the entire room,” Movassat said.

Students also report less dramatic observations involving routine care for the sick, the injured, and the newly born. “I have seen so many things I wouldn’t be able to see if I didn’t have this internship,” says Y-Nhi Nguyen, a junior who plans a pharmacist career. “It’s not just the healing processes. It’s every aspect. I always thought that the hospital was just about injury and disease. But it’s much more than that.”

Communication is key

It’s midday in the progressive care unit, and Santa Clara junior Brandon Au has just arrived for his intern shift. At the nurses’ station, on-duty nurse Kristina Suzuki brings him up to date on a couple of patients, and soon they fall into a discussion with two other nurses about communicating with non-English speakers. To keep up with the patients’ many languages, O’Connor contracts with telephone interpreters, but it’s not always the optimal solution. Family members can facilitate translation, but even they sometimes miss the nuances, as a Vietnamese-speaking nurse noticed when she overheard a relative incorrectly translating for a patient. Bilingual nurses could be called in, but that takes them from tending to their own patients, she said.

Au says he hadn’t previously realized the breadth of medical ethical
issues. Nurses have told him about society’s changing attitudes toward death, the growing expectation by the elderly that medicine can keep them alive despite debilitating illness. “They’ll say ‘I don’t want something pumping on my chest.’ They don’t want to spend their life on a ventilator. But they want aggressive treatment,” says Karen Denham, clinical manager of critical care. Au adds, “No matter what job you have in the hospital, you’re going to have to deal with those issues.” The internship, he says, has intensified his hope to blend a medical career with helping the underprivileged in his native Hawaii.

Au trails along after Nurse Suzuki as she checks on a patient who is surprisingly perky and
ready to go home after bypass surgery. Suzuki shows her how to squeeze a small “cough pillow,” whimsically decorated with a heart, against her chest to force deep, healing breaths. Au chimes in on the light conversation. “You’re feeling pretty good now?” he asks the patient. She smiles and nods. Down in the emergency room, intern Andrew Hennigan plies the nurses with questions about the hospital’s front lines. Geriatric patients, with ailments like shortness of breath and chest pains are frequent visitors here. This morning the E.R. has seen two heart attack victims. The full dysfunction of the nation’s health insurance structure is on display in this busy room where the initials of patients are listed in marker pen on a large white board. Too many people come in for primary care because they lack insurance to see a private physician. For those who can’t get themselves home, nurses locate transportation, but then worry about whether the patients actually will be able to get into their homes. These are situations that interns might not envision but for their rotation through the E.R., says Genie Giguere, emergency room clinical manager. “Here in the E.R. we deal with womb to tomb. It’s an environment they’re not going to normally see,” she says.

Hennigan agrees. “There’s something different every time I’m here. The nurses are really awesome about letting me ask questions and follow them around.” The junior biology major from Scottsdale, Ariz., speaks admiringly of what he calls the hospital’s “holistic approach,” involving social workers, chaplain’s staff, and health educators to support patients and families. Other students note this aspect as well. “They get a bird’s-eye view of the spiritual and emotional issues,” said Alice Doyle, a former social worker at O’Connor who now coordinates the intern program as assistant director of health care ethics in the Markkula Center for Applied Ethics. Thirty students have completed the intern program in its first three years, she said.

No easy answers

One of seven hospitals operated in California by the Daughters of Charity, O’Connor has an array of programs that underscore its mission to serve the less fortunate, including its Pediatric Center for Life, a clinic geared to low-income families. Dr. Thad Padua, hospital chief of staff and medical director of the pediatric clinic, sees Santa Clara students as a positive influence at O’Connor. Their presence, he says, “helps the professional staff keep on their toes. When you have a student walking around asking questions, it makes you think more on what you’re doing.”

He says interning offers students a window into multidisciplinary patient care and what Padua considers the major challenge for health professionals: “the ability to provide patient care in the best way we can without being influenced by other outside factors, non-clinical factors, business factors.”

Chris Cirone ’04 says his internship taught him that “nearly every decision made by a health care worker has an ethical component in it, be it whether or not to give a patient a possibly addictive pain medication, or to start life support on an elderly patient who will probably never come off of it. I found these questions particularly challenging, and I wanted to make them a part of my life.

“I observed a number of instances where patients were put on life support, even though it had little chance of improving their quality of life. This was often done because their families insisted upon it. These and other difficult situations made me realize that many of the ethical situations facing health care workers do not have easy answers.”

His internship solidified his career path, Cirone says. “I watched various workers put their hearts and souls into caring for their patients…Patients willingly hand themselves over to these workers, and at the drop of a hat will divulge the most personal of information to them. By the time I had finished the program, there was little doubt in my mind that I wanted to be a physician.“ Cirone is now a first-year student at Loyola University Chicago Stritch School of Medicine.

The start of life

In a softly-lit room where a dozen incubators are arrayed alongside racks of formula and towels, junior Rhea Hautea dons a white and yellow hospital smock over her black jeans. The Neonatal Intensive Care Unit is a favorite venue because it holds the exciting prospect of witnessing birth itself. On this day, Hautea smiles watching a nurse slide her hands into an incubator where a tiny infant nestles, eyes squeezed shut and miniature fingers wiggling like flower petals in the wind. The nurse gently adjusts the tubes attached to his translucent pink skin and then moves to his twin brother in the next incubator. The twins, now weighing between two and three pounds each, were born on Hautea’s first day in the unit.

She feels a special connection to these infants. But, she sighs, “We’re not allowed to hold them.” Her experience here has prompted new interest in a pediatrics career, and she seizes opportunities not only to question nurses, but to quiz the parents she meets here about cultural issues and child rearing.

Up on the hospital’s brightly-lit fourth floor, Elizabeth Fitzgerald, a senior combined sciences major, has arrived this day to a bit of flurry in the medical-surgical unit. A diabetes sufferer was found unconscious in his room, with low blood sugar. Fitzgerald has learned that diabetes can cause poor circulation to the feet and loss of limbs, as in the case of this amputee patient. She has arrived in time to observe a doctor and nurses stabilize him and attach an intravenous line. “It’s interesting to see the nurses that have been around a while and know what they’re doing,” she says.

Fitzgerald hopes to become a doctor, and after observing the physicians’ grueling schedules, she is considering specialities like dermatology that allow more time away from work. “I want to have a family some day,” she says.

Interning last year was also an eye-opener for Santa Clara senior Liz Wilson, a biology and psychology major. Her strongest impressions: the vulnerability of elderly people whose relatives take financial advantage of them, and the undue influence of insurance companies in health care choices. “These experiences made me realize the necessity to do the best we can for people in providing their health care as well as the intense need for health care reform,” Wilson says. An aspiring neurologist and psychiatrist, she now has an additional career goal. “It is solely because of this program that I want to pursue a master’s degree in public health because I realized how much of an impact ethics has on the level of care pe ople receive,” she says.

Being there for the family

Harman helps students explore the social and emotional aspects of her job, including the challenges posed by family members. “Almost every patient here has some critical issue, whether it be their fear of going home, or not having a place to go, ” or fatal illness, she says. “When you get someone in here and they’re very critically ill, you get all kinds of little family issues and dysfunctions out in the open.” Harman and her colleagues often find themselves part of the drama. “ People ask ‘How can you deal with this?’ You deal with it by being there for the family. I feel perfectly fine in crying with the family, hugging them. You have to see what’s best for the family. If they want 40 people in the room, fine. If they want no one, that’s fine too.”

Harman heads off with Horan in tow to meet a new patient who had open heart surgery the previous day. Walking past one glass-walled room, Horan recognizes an elderly patient talking with a visitor. He asks Harman if she is the same woman who, during Horan’s visit to the hospital a week earlier, was near death after surgery. “That’s her,” Harman replies with a grin. “Cool,” the student says. “She’s still here.”

Rita Beamish ’74 is an author and freelance journalist who covered the White House, politics, and foreign policy for the Associated Press for 15 years.