The Murder in Exam Room 15

Pasceri had always fawned over his mother, but now that his father was dead, he took steps to secure legal authority to make medical decisions on her behalf. The news frustrated Joly, a research scientist at a major pharmaceutical company who had quarterbacked her mom’s quadruple bypass a ­decade earlier. “It didn’t make any sense,” she says, but she didn’t challenge Pasceri over the decision for fear of triggering one of her brother’s infamous conniptions.

Widowhood was hard on Marguerite, and her health deteriorated. Late in the summer of 2014, she was back at the Brigham, barely able to breathe. Exams revealed that she had badly damaged heart valves; the necessary procedure happened to be among Davidson’s specialties. Hours before the surgery was to have taken place, however, Davidson called it off; Marguerite had a urinary tract infection, he told the family, and she hadn’t followed his instructions to take a prescribed antibiotic the previous day. The situation in pre-op grew tense as the family pleaded with Davidson to perform the surgery regardless of the infection, fearful that Marguerite’s heart would fail in the interim. “Dr. Davidson said, ‘No, I can’t do the surgery,’” Joly ­recalls. “‘You have an infection, it’s too risky.’”

Pasceri pushed the issue. “He was getting a little pissed,” Joly remembers. “You could see it on his face.” Davidson didn’t waver. He said if the family didn’t like his requirements, they could seek care elsewhere.

On October 2, 2014, Davidson operated on Marguerite. The procedure went perfectly. The day before her discharge to Fairlawn ­Rehabilitation Hospital, in Worcester, Davidson visited Marguerite’s room to wish her and Joly well. He complimented Marguerite on her recovery and said he’d be in touch regarding follow-up care. As Davidson walked out the door, Joly shouted, “Take care of those magical hands.” The 44-year-old surgeon turned and smiled.

Marguerite’s discharge didn’t go as planned. A few weeks into rehab, she was rushed to Saint Vincent Hospital, in Worcester, over concerns that she had a potentially fatal clot in her lung. Joly and Pasceri ­implored their mother to transfer to Brigham and Women’s, but 78-year-old Marguerite refused, fearing she wouldn’t survive the ambulance ride.

From the moment his mother entered Saint Vincent, Pasceri desperately sought advice from Davidson, whom Pasceri ­believed had saved her once before and could do it again. He faxed lab results to the Brigham and called Davidson’s office to keep the surgeon abreast of changes in his mother’s care. But, Joly says, “Davidson couldn’t be a doctor from 60 miles away. He couldn’t be her doctor. I don’t know what my brother expected.”

After spending nearly a week at Saint Vincent, Marguerite received a visit from her cardiologist late one night. “He was very uptight and nervous,” Joly recalls of the doctor, who had serious concerns about Marguerite taking the drug amiodarone. Given the blood in her lungs, and that one of the side effects of amiodarone can be lung ­inflammation and bleeding, he suggested that the medication might be tied to some of her pulmonary problems and said he was pulling the drug from Marguerite’s regimen of pills. (Citing patient privacy, Saint Vincent declined to comment.) The brief encounter unsettled Joly. She pulled out her laptop and began researching amiodarone, a common heart medication that was approved by the FDA almost 30 years ago. She relayed the episode with the cardiologist to her brother and shared with him the drug’s long list of potential side effects.

Marguerite’s condition continued to ­deteriorate. After running a painful blood-gas test on Marguerite, her medical team came to her with a grave decision: If she wanted to live, they would need to intubate. This meant sliding a large tube down Marguerite’s throat and hooking her up to a breathing machine. Pasceri panicked. He hovered over his dying mother and peppered her with questions. “He wanted to know, ‘When do I pull the plug? When do I not pull the plug?’” Joly says. Marguerite snapped. “Tell him to shut up,” their mother snarled from her deathbed. Joly stood by in disbelief: In 50 years she had never seen her mother admonish her brother like that. “His jaw fell to the floor.”

As they decided whether to intubate, the family’s conversations with the medical team at Saint Vincent danced around the subject of death without broaching it directly, only tacitly acknowledging the possibility in vague terms: We’ll see how it goes. “Through all of this, there are no doctors talking to us about end-of-life issues or a scenario where she could die,” Joly says. “It was always, ‘Let’s do this, let’s try this.’”

In finding themselves lost at the end of the road, Marguerite’s family was not alone. Weighing a loved one’s quality of life—as opposed to her quantity of life—is a task few families, including Marguerite’s, are well equipped to handle. “End-of-life care in America is broken at every level, and it needs to be entirely overhauled,” says Dr. Angelo Volandes, of Massachusetts General Hospital. “Most people are thinking about television, where everybody survives CPR, where everybody looks like George Clooney on a breathing machine, and the miracle cure for their disease is right around the corner.”

Volandes is troubled by what he calls America’s “denial-of-death” culture, and he has spent years studying the ways doctors and families conduct end-of-life care decisions. The conversation—the point at which a doctor, patient, and family start discussing what a good end of life means to them—“is the most important procedure in medicine,” he says, albeit one for which most doctors are ill prepared. “We expect our doctors to be master communicators, but we don’t train them to be so.”

It’s not just doctors who need help broaching this subject. Volandes says families should be having these talks long before illness strikes—or soon after a foreboding diagnosis. There are tangible benefits to doing so: A 2010 study showed that family members who planned in advance for end-of-life care with ill loved ones were able to grieve better, and experienced markedly less stress, depression, and anxiety.

On the other hand, families that don’t talk about these issues may face strife, confusion, and heightened grief at the most vulnerable moment imaginable. “The absolute worst time [to start talking about end-of-life care] is during a crisis, when decisions need to be made,” Volandes says. “Because no one has started the conversation with their mom or dad, or gotten the kids in the mix, what ends up happening is these family dynamics play out in the hospital. Now we have different children with different priorities, and Mom is usually intubated and can’t speak for herself. Now we’re stuck with the discord of family dynamics that have probably been playing out for years.”