Fortitude

You are the chief resident in internal medicine on the admitting team at the hospital. You’ve just supervised the admission of Frank—a frail, middle-aged man diagnosed over a year ago with metastatic cancer of the mouth and throat. You’ve participated in his admissions and bounce-backs many times, working with fellow residents and faculty to coordinate social support and care.

A life of unhealth, addiction, and violence seems to have led irrevocably to Frank’s profound alienation from family, friends, and medical resources. As if driven to the point of no return, Frank has no-showed visits, left against medical advice (AMA), and refused to see specialists. You’ve hung your head as he has been systematically kicked out of every boarding home and refuge in the area. His family has stopped answering your calls.

During this admission, Frank is almost unrecognizable, he is emaciated and brittle, and in terrible pain. Your team has admitted him in part because he is threatening to take his own life. As you visit his hospital room, he demands food through a truly impressive repertoire of profanity, garbled by the surgical removal of part of his tongue. Even when he is asleep, the folds and furrows of his face seem locked in an expression of bitterness and misery.

No one on the medical team seems to like Frank. Even the most empathetic among your staff are seemingly unmoved by him at this point. As the team discusses his care during rounds, a medical student asks what it means to respect the choices of patients like Frank. Someone says, “I guess it’s an autonomy thing.” A fellow second year resident says, “He made his bed; he can sleep in it.” An intern says “We’ve done everything we can possibly do.” Another senior resident on the team puts it bluntly: “The best we can do in this situation is discharge him with pain control. He’ll probably come back again in two weeks or die on someone’s doorstep.” The medical student asks, “I mean, I don’t think we can just abandon him, but does he just want to die?” An older attending chuckles, saying “What we need here is not a TOC, ‘transition of care,’ but a TOB – ‘take out back.’” The team nervously laughs before a silence falls over the rounding room. One of the senior residents looks at you and asks, “What do you think about Frank? You’ve known him the longest. What should we do?”

Adapted directly from: Brewer Eberly, “Saving Friends,” Plough Quarterly 2023:23-27.

Discussion Questions

1. What is the moral challenge that you need moral courage to face?
2. Is it your place to stand up for Frank even after he has made poor decision after poor decision?
3. Should you correct your team who are justifiably frustrated with Frank?
4. How do you accompany your patients even in the face of death and suffering?
5. Could this be an occasion for the vice of fearlessness? How about the vice of cowardice?
6. Would unrealistic expectations and conversations be a manifestation of fearlessness?
7. Would most of us shy away from difficult conversations with Frank or our own medical team?
8. Do we fear the reaction or judgments of others when speaking up?