By Cheong Pak Yean
Beneficence and non-maleficence are two key pillars of medical ethics. In the doing of good we must guard against doing unintended harm.
The Heart That Would Not Stop Beating
It was the late seventies. I was young and energetic and monitoring patients in the intensive care unit. During one of my night watches a patient was rushed in directly from the emergency department after her family had found her unconscious. Tubes were efficiently inserted. Chest compressions. Ventilation. Bloods. Cardio version. We were in control. The mechanical thumper was brought in. This lady was extra small, but we got the thumper working on her after a while. Just as we thought we had stabilized her, her rhythm became chaotic again. Just as we wanted to stop resuscitation, it returned to sinus. These cycles went on for over two hours before her heart mercifully stopped beating.
Two days later, I happened to read her obituary in the newspaper. There was a short essay attached, entitled The oldest person in Singapore died peacefully in hospital. She had been a hundred years old. Her last hours had been spent amongst strangers fixated on her heart rhythm to the point of absurdity. I would not have used the word peaceful.
Commentary
In the drawing, the medical students depict their experience of a bed-side tutorial. Their tutor, the dark figure, lectures a captive entourage of befuddled medical students about hypertension. He is oblivious to the expletives hurled by the agitated man restrained to the bed. Only the little child in the female medical student, all innocence and as yet unacculturated by the medical system, steps forward and exclaims Oh no! in empathy. The tutor has unwittingly displayed poor role-modelling of professional values whilst providing medical training.
I confess that as a young doctor, there are times I provided good care without reference to the patient. One such experience is recounted in the vignette. Following intensive care unit protocol, I mindlessly helped to keep the heart of the oldest woman in Singapore beating.
Years later, I had another elderly patient in a nursing home. She was ninety and had been bed-bound and uncommunicative for four years, and she had a Do Not Resuscitate* directive in her charts. Despite this, she was defibrillated when she collapsed in the home and brought to hospital. In the hospital, her children requested that no radiological or blood tests be done and no intravenous lines be set up. She remained in sinus rhythm** post-defibrillation for a few hours and her children were able to bid her farewell.
May we apply our knowledge and expertise with wisdom and empathy.
——-A/Prof Cheong Pak Yean
*A Do Not Resuscitate, or DNR, directive is an indication to the medical team to allow natural death in the event of a collapse. The default action that healthcare workers will take in a case of patient collapse is to resuscitate, including using the defibrillator machine.
** Sinus rhythm is the normal heart rhythm.
Cheong Pak Yean is an internal/family physician & psychotherapist. He is an SMA honarary member, past president of SMA, College, and adjunct Assoc Prof of NUS. His current interest is in medical communication & humanities.
The commentary and vignette were reproduced with permission from the book “Being Human, Stories from Family Medicine” edited by Cheong Pak Yean and Ong Chooi Peng and published in 2021 by the College of Family Physicians Singapore.
Pictures of illness experiences were drawn by NUS medical students in workshops conducted from 2012-2017 by A/Prof Cheong Pak Yean. Senior family physicians subsequently shared vignettes and commentaries based on the pictures.
