One final sip.

The patient was in his 70s but appeared much older. Speaking in broken sentences, he nervously stated that he could not breathe. With each exhalation there were discomforting squeaks and whistles; with each intake of breath his nostrils widened, the muscles on his neck contracted, and his belly moved down towards his torso, making shallow craters in his abdominal wall. His lips had a bluish hue, and he said in barely discernible speech, “I have cancer.” There was guilt in his voice. “I’m so sorry,” he said, “I’m so sorry.” The physician grabbed the man’s cool and clammy fingers, and rested them firmly against the palms of his hands while his internal autopilot shouted audible orders. “I need 125 milligrams of Solumedrol. He’s tiring out. I need 40 milligrams of Lasix. Someone get him a breathing treatment!” The human being remained distant from the autopilot, though they existed in the mind of the same young physician. The human being remained at the bedside watching the patient, meticulously noting subtleties in his emotional health. A tear drop fell from beneath the patient’s left eyelid, a sense of submission in his eyes softly saying “Yes—the cancer has won. It is over.” “I need the continuous positive airway pressure device,” the autopilot calmly stated. “He is tiring out.” “Sir, we are going to try to put on a machine you to help you breathe.” The patient nodded in acknowledgement. The tears continued to flow from his left eye, and he glanced at the human being at his bedside, eyes asking, “What is taking so long? Am I finally going to die? Will I suffer? When will this end?” The patient’s wife was brought to the bedside while the autopilot, with a sense of calmness, confidence and urgency, spoke to the patient. “Sir, I need to know a few things. You are having trouble breathing on your own. I need to know if it is okay if we put a tube in your mouth and down your throat into your lungs to help you breathe.” The patient closed his eyes. “Do you have an advanced directive?” The wife rushed into the room and with tears in her eyes, sobbed “Please don’t leave me! I’m so sorry, please!” “Sir, we don’t have much time. We have to make a decision,” the autopilot calmly replied. The patient opened his eyes. Another tear fell. He looked nervously at the human being, then at the autopilot calling out orders. He removed his fingers from the protective grasp of the human being’s hands, and with an uneasy tremor pointed his index finger up toward his wife. The autopilot, caught off guard by this gesture, as it was not part of the usual protocol, replied, “Do you want your wife to make the decision?” The elderly man gave one deep breath, nodded with a sense of affirmation and again closed his eyes. The wife paused. She looked at the physician. A steady stream of tears ran down her cheek. “Yes,” she cried. “Oh, please yes—don’t let him go! I want you to make him breathe! Please put him on a breathing machine!” The nurse standing behind the autopilot’s right shoulder whispered, “But Doctor, he has stage four lung cancer.” The futility of treating this patient was understood by all who were present in the patient’s room: the patient, his wife, the nurse, the human being and the autopilot. These latter two looked around the room for almost 30 seconds. Finally, they looked at the patient and then at the wife. The patient’s eyes remained shut. There was a sense of agony in each breath he took. Wires ran across his body attached to electrodes like an electrical circuit. He no longer resembled the elderly man they had seen just a few minutes ago. Alarm bells rang from the telemetry monitor. With each passing second, it was increasingly clear that a decision could not wait. With a loud sigh, the autopilot looked at those gathered and said boldly, “Let’s intubate!” The button had been pushed. An algorithmic barrage of technology and medication was deployed on the elderly man. The human being backed out of the room. Outside, he took note of a diet soda perched against the wall across the hall—the same diet soda he had left resting there a few hours ago. Loud alarms rang in his ears, telling him the ventilator had just been connected. He looked at the soda one final time and thought about Malawi. Two months earlier, another battle between life and death had unfolded right in front of his eyes. That battle occurred in an environment where the mere presence of a young physician at the bedside meant more than technology could ever offer. It was a scorching hot April afternoon in Malawi with the sun beating down hard against the muddy dirt roads leading to the government hospital. Drenched in sweat, I passed the fields of maize winding around to the busy bus stop parked outside of the hospital. Scores of patients, family members and hospital personnel entered the complex and disappeared behind its aqua blue painted walls. I approached a vendor on the street and bought a diet soda. I took one sip and gave a loud sigh. Behind those aqua blue walls lay a world dire in resources, where suffering occurred in silence. Like all afternoons, I started my rounding on the general medical wards, looking into the eyes of each patient to see which patients were the sickest of the sick and needed immediate attention. I took notice of a girl in her 20s—completely naked, grunting, vomiting frank red blood and shivering vigorously. I had seen her a few weeks earlier in this same bed and noted the manner in which she was shaking. Where were her family members? Why was she all alone? The human being and the autopilot fought to see who would come out first. The girl looked at the human being with death in her eyes. Her eyes sunk so deep he felt he could glimpse loss of hope and passivity within the inner depths of her soul. She was submissive to her surroundings, submissive to the mercy of the people around her, and submissive to time. Was she also now submissive to the idea that she was close to death? In an instant, the autopilot switched on but there was no one to receive his orders and little with which to transform those orders into action to help the patient. This was not a hospital known for technological wonders and cutting edge resources. This was a different world. At full speed, the autopilot began to execute on a whirlwind of ideas: “Where is the central line kit?”; “She needs IV fluids!” “Someone run to the blood bank!” “Hurry, we have to save her life!” After a quick glance at the chart, it was noted that the girl had a platelet count of 8, and a CD4 count of less than 50, and was being treated for every possible infection common in an HIV-positive individual. For a moment the autopilot and the Malawian girl locked eyes, looking at each other as if both were seeking some sort of agreement on what to do next. He held her hand and in an instant, the human being materialized—the same human who would emerge at the elderly man’s bedside two months later. The girl’s ice-cold hands now lay in his palms. Her sheets and the olive skin of her face were covered by dry, foul-smelling blood. If this patient was going to die, he decided, she would die clean with some dignity. He moistened a wet cloth with cold water and wiped her face, her mouth, her cheeks and her neck. She appeared to be momentarily comforted by the touch of cold water, closing her eyes and letting out a sigh. He massaged her head and then her temples, and finally, her shoulders and arms. Her bed sheets were changed, as well as her tiny blood-stained blanket. The human being propped the patient’s head on a stack of blankets to raise the head of her bed and borrowed some juice from a patient nearby. The girl opened her tiny little mouth, took a sip—then two—and finally mumbled something that was taken as “That’s it—thanks.” The girl then closed her eyes one final time. She did not wake up. Outside the elderly man’s bed in the Intensive Care Unit, I looked at my soda then took a sip. I could hear the sounds of alarms buzzing from the connected ventilator. I felt then that the wrong part of me had won—that technology had distracted me from what it seemed this man wanted and needed: human connection and acknowledgement of his impending death. I should have given him something other than a breathing tube—something closer to the one final sip I gave that girl in Malawi two months earlier.