Too many cooks...

Long before he passed through the entryway of Downtown Memorial, Matthew Wexler instantly regretted many of his decisions from the prior evening. While he would’ve paid any price for the right to call out and climb back into bed, he knew the optics weren’t in his favor considering his less than subtle appearance at the annual Neurology Department Gala. And while the details remained fuzzy, his friend’s social media post of him grinding on the dance floor with one of the attendings told Matthew everything he needed to know. 

“Late night, stud?” offered Dr. Chandra Singh, who was unable to hide her grin as she held the elevator. 

Matthew reluctantly joined her for the ride to the Neurology office on the fourth floor.  

“Please tell me it wasn’t as bad as I think it was?” he asked his friend and fellow resident. 

Not letting him off the hook so easily, she replied, “You tell me. Will Dr. Patterson be doing the rounds of shame in the same gown she wore last night?” 

“Very funny. Very funny!” Matthew rolled his eyes. “I’m just happy she’s not the service attending this month!” 

“That’s probably best for many reasons,” agreed Dr. Singh. “But I’m not sure if Dr. Kendall will let you off so easy. She’s pretty sharp.” 

Arriving at the fourth floor, Matthew Wexler lowered his eyes and walked toward the office for morning report and to collect the new consults. 

After grabbing a much-needed cup of dark roast, Drs. Wexler and Singh joined the overnight doctor, Martin Dorne, and Dr. Stacey Kendall in the conference room. 

“Good morning team,” began Dr. Kendall. “So glad you were able to join us Dr. Wexler. After last night, I had my doubts.” 

Matthew blushed and again dropped his head toward the floor while his colleagues couldn’t help but giggle at their attending’s dig. 

“I’m sorry. I couldn’t help myself. After all, there’s a long-rooted history of residents and attendings making poor decisions when partaking in the open bar. There is also a tradition that the offending resident must redeem himself by taking the most difficult consult from overnight. And I believe I’ve found the perfect one... You are looking for a little redemption this morning? What do you say, Dr. Wexler?” 

He nodded. Anything to remove the spotlight from his being. 

“Excellent. That’s the spirit... So, for you I’ve hand selected the case of 102-year-old Hilde Koch, who sadly is unlikely to reach her hundred and third birthday next month. She was admitted last night unresponsive, and her CT scan shows a massive stroke with intracerebral hemorrhage and edema.” 

When Dr. Kendall paused, Matthew appeared perplexed, prompting his attending to question his reaction to the case. 

“Is it the hangover, or is there something you find odd about this case?” Stacey Kendall inquired. 

“Not at all,” Matthew replied. “It’s just that you said my punishment was a challenging case. Though very sad, there’s nothing to do for this hundred-year-old woman?” 

Dr. Kendall smiled. “Dr. Wexler. Go forth and seek your redemption! Just please do me a favor and text me the ‘hand on head’ emoji when you finally understand. My evening wasn’t as exciting as yours and I can always use a pick-me-up during the workday!” 

When morning report had concluded, Dr. Dorne was dismissed home to sleep, and Drs. Singh and Wexler headed off to see their cases. While they both boarded the elevator, this time Matthew exited two floors down, while his partner continued to the ER.  

The second floor of Downtown Memorial Hospital housed the ICU, CCU, operating rooms, and their respective waiting rooms. To reach the ICU from the elevator, Matthew made a quick right, but before he could even see the door, he was greeted by an unexpected scene; the typically quiet hallway was jammed packed with a large gathering of Orthodox Jewish family members who poured out of the nearby waiting room. The visitors, dressed in traditional garb, parted just enough for Matthew to squeeze into the ICU. 

Once inside, Dr. Wexler was greeted by Nurse Maureen Keller.  

“Hey doc. You from Neurology?” she asked. 

Matthew shook his head affirmatively. 

A wicked grin appeared on her face. “Well, then it looks like I’ve got around fifty visitors waiting for you.” 

“Excuse me. What are you talking about?” he attempted to clarify. 

“I mean, that’s the family for Hilde Koch. And they’ve been waiting since last night to speak with every doctor who sees her.” 

“Ok, I’ll take care of it,” the young resident placated the ornery nurse before removing his cell phone and texting Dr. Kendall the single emoji.  

Matthew Wexler sat down at a computer, reviewed Mrs. Koch’s chart and imaging, and prepared to meet his patient. Inside the room were an elderly man with a short grey beard wearing a yarmulke and a seventy plus year old woman wearing a long, dark house dress. Matthew entered the room and approached the family members who were seated beside Mrs. Koch.  

“Good morning, my name is Dr. Wexler and I’m from the Department of Neurology.” 

The woman took the lead and introduced herself as Frida Hendel, Mrs. Koch’s eldest daughter, and the gentleman, the patient’s brother, whose name was Max Hoffman. Having served as Mrs. Koch’s caretaker since the passing of the patient’s husband more than a decade ago, Mrs. Hendel felt comfortable providing her past medical history, which remarkably, for a woman of such an esteemed age, only consisted of mild hypotension and osteoporosis. And although her mobility and cognitive processing had progressively declined over the past few years, her family was able to maintain a semblance of quality to her life, be it in a wheelchair, and in between extended periods of sleep. 

Mrs. Koch’s daughter next explained that her mother was in her usual state of health two days prior. She even ate most of her dinner, pureed vegetables and beef, before heading off to bed. Yesterday morning, Mrs. Hendel noticed mom was difficult to arouse at nine-thirty. Given this wasn’t an unheard-of scenario, she allowed her to sleep a few more hours however became worried when she still wouldn’t awaken by mid-afternoon. She also questioned whether her mother's face was drooping on the right side.  

Frida Hendel immediately consulted her younger brother, Chaim, a doctor of Internal Medicine. With his mother’s diagnosis and prognosis, unfortunately, easy to arrive at, he determined there was no alternative but to call for an ambulance. Frida dialed 911, and her brother activated the family phone chain which reached Hilde Koch’s eight children, twenty-seven grandchildren, and twelve great grandchildren. 

When he finished his limited examination of the comatose Hilde Koch, the resident sat down with Frida Hendel and Max Hoffman, explained his findings, the CT scan, and the overall picture. Despite beginning in his third and final year as a Neurology resident, Matthew typically found these interactions difficult, but thought this one would be less so. It wasn’t that he that he necessarily needed any reason, beyond her years, to justify Mrs. Koch’s present condition, however, Dr. Wexler assumed from the history that the family had likely been preparing for her passing for quite some time. As he swiftly identified, he couldn't have been more wrong. 

After describing the severe nature of the stroke which in his estimation had caused extensive, irreversible brain injury, he decided to inquire whether Mrs. Koch had a Living Will or had expressed whether she’d want to be kept alive using artificial means, like the ventilator currently breathing for her.  

“There are mechanisms which allow for her to come off the machine if she wouldn’t have wanted to be kept alive artificially,” Dr. Wexler clarified after bluntly providing the family with zero hope for recovery. 

“Thank you doctor,” politely responded Frida Hendel, “but my mother doesn't need to have a Living Will. GOD is her Living Will. He will take her when he is ready.” She then nodded in agreement with her uncle. 

“But Mrs. Hendel, Mr. Hoffman,” Matthew Wexler interrupted their moment. “I’m not sure if you understand. I just said that your mother is never going to wake up or communicate in any meaningful way. Why would you want her kept alive on a machine?” 

Unfazed by his challenge, the patient’s daughter answered, “I know we come from different backgrounds, but we believe in the same GOD. And it is my community’s belief, that only GOD can create or take away life, not man... Doctor, I will miss my mother when she passes, but this is not for me to decide.” 

“And this is what Mrs. Koch believed, too? She shared her opinion specifically about this issue?” clarified Dr. Wexler. 

“She didn’t have to, young man,” stoutly confirmed Mrs. Hendel. 

Although he firmly disagreed with Mrs. Koch’s family on this issue, Dr. Wexler decided it was best for now to move on. Then again, with no intervention to offer his patient, he believed his role in her case was limited. Matthew stood up from his seat and was about to exit the scene when Mrs. Hendel had one last request. 

“Doctor, thank you for your time. On your way out, would mind updating the rest of Mrs. Koch’s family?” 

And while he could’ve declined, explaining that he typically only spoke with the primary family representatives, the empathic Matthew Wexler went against his better judgment and agreed to her request. Frida Hendel escorted him out toward the waiting room which was only able to hold approximately half of her relatives. Inside, family members of the same religious persuasion filled the room. Some were sitting in chairs, comforting one another, and a handful were standing, praying while rocking back and forth. 

When she’d gathered everyone’s attention both inside the room and beyond its doors, Dr. Wexler repeated the same gloom-filled update. The reactions varied greatly from stoic acceptance to tear-filled devastation. Before he concluded, though intimidated by the sheer volume of his audience, Matthew opened the floor to questions. And while very few emerged and simply confirmed the woman’s poor prognosis, a younger, less traditional woman wearing jeans and a hooded sweatshirt stepped forward. 

“Doctor, how long can my grandmother remain alive in this condition? Is she suffering?” 

Dr. Wexler hesitated before answering. Choosing his words carefully, he replied, “From my examination, Mrs. Koch doesn’t appear to be in pain. And with respect to timing... Regrettably, there’s no way to know when she will pass. Doctors are able to keep their patients alive for a long time using modern technology.” 

The woman, who Matthew later learned was the youngest of Mrs. Koch’s grandchildren, Sadie, then upped the ante, inquiring, “What if she never wanted to live this way? Is there something we can do to help her?” 

Sadie Koch wasn’t naïve and immediately knew the firestorm her question would generate. Frida Hendel and her brother Samuel stared down the young woman whose rebellion went far beyond her dress. Her father, a bearded fifty-plus year-old man who blended with his kin, wearing a black suit with traditional fringes falling from his sides, quietly advised his daughter in Yiddish to keep her mouth shut. There were also other anonymous whispers from the crowd outraged by Sadie’s sacrilege.  

Before Matthew Wexler could even address her questions, Mrs. Hendel jumped in, again verifying, “Thank you, Doctor. Pardon my niece. She is young and misinformed. As I explained at her bedside, my mother believed in life until GOD is ready for her... In addition, our Rabbi will be coming this afternoon to provide guidance regarding mom’s condition, and the last of Mrs. Koch’s great grandchildren is flying in from Israel to be here. In fact, she is the only living member of the family not currently present.” 

The resident, who was of similar age as Sadie Koch, wanted nothing more than to support the young woman, yet realized the power of numbers and tradition. Instead, he subtly bowed his head and excused himself. Sadie also decided it was time to take her leave rather than face the wrath of her family and followed Dr. Wexler toward the elevator. 

“Doctor, doctor,” she called out to the unsuspecting Matthew Wexler who had yet to press the call button. He turned to see who sought his attention and was grateful for which member of the Koch family it turned out to be. 

“Oh, hey. Are you ok? That must’ve been difficult,” he cordially replied. 

“Tell me about it. Well over fifty members of my family are present and as you can see, I’m the only one who shamed their family by joining the modern world.” 

“I’ll say it again,” offered Matthew. “That really must be difficult! I’m assuming you’re not here for the abuse.”  

Sadie chuckled. “Not exactly. I’m only here to for my Grandma Hilde. As you probably can understand, these days I tend to avoid my extended family. I believe it’s best for everyone. Except for a few of my cousins who are too scared to make choices similar to the ones I’ve made, Grandma Hilde was the only person in the world who supported me. I wanted to be here to say goodbye.” 

“I’d say that’s kinda surprising, but unfortunately, I was never able to meet your grandmother,” explained Matthew. “I’m so sorry for your loss.” 

“Thank you,” Sadie accepted his heartfelt condolences. “And not that it helps much, but I wasn’t lying. My grandmother had confided in me multiple times when she was more coherent that she’d never want to be kept alive on machines and tortured by doctors... No offense.” 

Matthew smiled. “None taken... That’s what we do best! But if those truly were her wishes, they should be followed.” 

“I agree, but without a Living Will, my Aunt Frida has made herself the unofficial health care proxy. And as you can see, she is a very strong woman!” 

  After parting ways with Sadie Koch, Matthew completed his morning consults. Just past noon, he found himself back on the second floor and poked his head into the ICU. Inside the room of Hilde Koch, Matthew could see Frida Hendel and a distinguished elder gentleman in traditional religious clothing. He appeared to have concluded a prayer, said a few words to Mrs. Hendel, and was now walking out of the ICU in the direction off the extended Koch family. Matthew decided to check in on his patient. 

“Mrs. Hendel how are you?” inquired Dr. Wexler. 

“Doctor, I didn’t expect to see you again today... Mom appears stable. Is there something I can help you with?”  

“No, I was just checking in, but do you mind if I ask you a question?” 

Frida Hendel nodded her head allowing his inquiry. 

“So, I was talking with your niece. She explained that your mother had stated she didn’t want to be kept alive artificially. Did she ever express this to you or anyone else?” Matthew Wexler asked, cautiously taking a physical and metaphorical step back while he awaited her response. 

“Doctor, you must excuse Sadie. She is a troubled young lady, but we love her all the same. That gentleman who just left this room was Rabbi Herschel Geiger; a most wise and learned man. You should know that we discussed this very issue and how it pertains to Jewish law. And after praying for my mother, he confirmed what my family and I have been saying all along; that we should cherish life above all else until GOD deems it appropriate to take away. Until that time, this is the path we shall follow.” 

Frustrated by her faith and lack of independent thought, Matthew politely questioned, “I mean no disrespect, but why do you need an outsider to determine your mother’s wishes?” 

Mrs. Hendel replied, “First, he is not an outsider. And second, my mother’s wishes are aligned with GOD’s... I bid you good day, Doctor.” 

Matthew graciously accepted her cue and exited the ICU.  

The following day, Dr. Kendall decided there wasn’t a medical indication to visit Mrs. Koch. And with memories of his performance at the gala having faded, Matthew enjoyed a more normal day and was walking out the front door when he spotted Sadie Koch. 

“Hi, Ms. Koch, hope I didn’t startle you.” 

“Oh, no. Nice to see you again,” greeted Sadie. 

“How’s your grandmother?” Matthew inquired. 

“So, you didn’t hear what happened?” she questioned, to which the resident shook his head. 

“Well, my family held firm in their beliefs and my grandmother clung to life overnight. In fact, it appeared that her vital signs were stabilizing, and the ICU doctor hinted that we’d soon have to make longer term plans for a feeding tube and a tracheostomy. What a nightmare that would’ve been! And then something miraculous happened.” 

Matthew Wexler was intrigued. “What happened?” 

“Well, my niece Sarah, you know, the one studying in Israel finally arrived and said goodbye to her great grandmother. Can you believe she passed away fifteen minutes later? I felt so relieved. My Aunt Frida walked over and gave me a big hug. Do you know what she said?” 

Matthew again shook his head. 

She said, “It appears GOD is now ready for Hilde Koch!” 

“I’m so sorry about your grandmother,” Matthew again offered his condolences. “But the coincidence is remarkable... I can’t imagine growing up in your family... Great grandparents, grandparents, parents, siblings, nieces, nephews, cousins, rabbis. I’m curious how decisions were ever made.” 

Sadie grinned. “You do know what ‘Koch’ means in English?” 

Matthew shook his head. 

“It’s German for cook... Now imagine the impact of this many Kochs in the kitchen at the same time!” 

The two shared a final laugh. Before they parted ways for the final time, Matthew considered inviting Sadie out for coffee, but immediately thought better of it considering her recent loss and also having had the benefit of already meeting her family.