I’d like to tell you a story, two stories, actually.

I was receiving sign-out the night before coming on service in the Neuro ICU when the Attending signed out a “disastrous family member.” The patient was severely injured by a prolonged cardiac arrest, was ventilator dependent, with complete loss of cerebral gray matter on MRI and flat line EEG but his wife was insistent that he receive tracheostomy and feeding tube for long term placement. There had been threatened law suits on both sides and no communication in more than a week. I actually received a call about the situation from our Chief Medical Officer later that night.

I can’t tell you how unusual that is. Maybe once every five years this level of discord will occur. Maybe less. Anyway, Buddha says, “No matter how difficult the past, you can always begin again today.” Changing Attendings is a good opportunity to try something new. So Monday morning I called his wife. There was no answer so I left a message. “Hi, this is Dr. Newman, I’ll be taking care of your husband this week. Please call the ICU so we can speak.” About an hour later she called and asked for me. I said “Hi!” again, she said “When will you do the trach.” I said, “After I meet you. When can you come up?” After a brief pause, she agreed to meet the next day. The discussion that followed was unprecedented. I don’t recommend it as a routine but circumstances were unique. Buddha also counsels us that when dealing with difficult people, we should “Imagine that each person in the world is enlightened but you. And that each person knows exactly the right thing to say and the right thing to do to teach you perfect patience, perfect wisdom and perfect compassion.” It is never easy to learn this way but it happens. Something from every patient.

The lady presented on the unit the next morning with her teenage son. There was nothing visually outstanding about either. I brought them to a small conference room and she and I sat directly across from one another at a small table with her son at her side. Not really knowing how to proceed, for reasons that I cannot explain, out of the blue, I began by saying, “Before we start, I’d like us each to agree on one thing. I will agree that everything that you say and do, you say and do because you love him. I want you to agree that everything I say and do, I say and do because I want to avoid unnecessary suffering for your husband. I’ll agree if you will.” She sat back and looked me in the eyes for several long seconds. And then she responded, “OK.” 

We then proceeded to have a perfectly ordinary discussion, not much different than I would have with anyone else. In the end, I could not dissuade her from a course that all of the staff abhorred, but her relationship with staff became appropriate, almost cordial. He died, after having had the trach and PEG, almost immediately after transfer to a nursing home.

I don’t ever remember using the term “unnecessary suffering” prior to that, in more than 40 years of practice. But I was amazed at how succinctly it summarized some very complex issues. That’s the first story.

As often happens, a similar situation arose shortly thereafter. In fact, the very next day I was asked by the medical ICU team to help a family member of another severely injured patient. The family member was having difficulty accepting the prognosis and wanted to proceed with trach and PEG even though the medical team believed further care to be futile. There was no animosity involved, it was a normal relationship.

Osler has two rules that we will discuss in the next chapter. “If it works, do it again. If it doesn’t work, don’t do it again.” These are profound rules and I believe in them deeply. Anyway, “unnecessary suffering” had clearly worked once, so I purposefully intended to “do it again” with this family member. The family member asked to speak by phone. I don’t like that but agreed. I reviewed the chart, saw the patient and we had a relatively routine discussion. He had clearly understood and digested the medical team’s information. So after our discussion I said, simply, “You need to understand that your father’s doctors really care about your father and they just want to avoid any unnecessary suffering on his part.” The phone went silent. I don’t know how long but it was long enough that I checked the phone display to ensure that we hadn’t been disconnected. Then he said, “Doctor, you should bottle that! No one has ever said that to us. We have been wondering why they were advocating to allow him to die. Was it a matter of money? Did they need the bed? Are they hiding something? No one has ever said anything like that to us. Thank you. I’ll pick up again with the medical team. Good bye” And he hung up. But that’s not the end of story.

I immediately went to speak with the MICU Attending to update her, of course. When I told her the same two stories that I just told you, she hit her forehead with her palm and said, “I have NEVER said that in any family meeting, but I will never have another family meeting where I don’t say that.”

 Later that day, the son called the MICU Attending and let her know that the family agreed that withdrawal of life support measures and comfort care were what the patient would have wanted and they set up a time for palliative extubation.

We learn from our patients and sometimes from their families. Buddha knows.

(Excerpt from Newman GC, “Chapter 12. Introduction to the ICU.” in Advice for Young Doctors, Philadelphia, 2025.)

George Newman MD PhD.

Professor of Neurology. Sidney Kimmel Medical College, Philadelphia. Chair Emeritus of Neurology Einstein Medical Center

Experience includes directing 4 Neurology residencies, director of 3 stroke program (SUNY Stony Brook, U Wisconsin and Einstein), 50 primary research publications, including early use of DWI for stroke and theory and practice of measuring CBF by MRI and CT, and Chief of Staff at the Northport VAMC. I have received over 2 dozen teaching awards from 6 different institutions involving thousands of students and residents.

My current interests all focus on medical education. My recent book Advice for Young Doctors (Amazon, etc) summarizes most of what I hope to share but that book and other ideas continue to develop as I teach at Einstein and SKMC.