One SHIFT San Francisco, 2010 Donna was in her mid- sixties, with wide brown eyes and the smoky voice of a jazz singer. Her skin, sprinkled with freckles and sunspots, stretched tightly against her delicate cheekbones and jaw. It was an unusually balmy afternoon in San Francisco, and somehow the day''s heat and humidity had made its way into her room on the fourteenth floor of the usually chilly university hospital. Donna grasped a handheld electronic fan, closing her eyes as it cooled her face and tousled strands of the thin gray- brown hair that brushed her shoulders. When I met her, I was a fourth- year medical student weeks away from graduation, yet increasingly uncertain that medi­cine was the right career for me. Five years earlier, Donna''s kidneys began to fail from a combination of high blood pressure and diabetes. She was weak and nauseated, and missed so many days at work that she nearly lost her job as a secretary in a contrac­tor''s office. In order to feel better and to survive, Donna had to begin dialy­sis, a three- hour- long treatment three times a week that would clear her blood of the waste products and toxins that her failing kidneys could no longer remove.

A vascular surgeon operated on Donna''s arm to create a fistula, a connection between an artery and vein that enabled the dialysis machine to remove, clean, and return all of Donna''s blood to her body. For the first few years, dialysis not only staved off death but actually improved her energy and outlook. She went back to work part time. Her nausea vanished and she managed to gain back the ten pounds she''d lost when kid­ney failure claimed her appetite. But a few years later, her nausea and fatigue returned; dialysis began to cause the symptoms it had once fixed. Donna cycled in and out of the hos­pital with severe infections of the skin around her fistula and blood clots that plugged her fistula, rendering dialysis impossible. During a recent hos­pitalization, a team of physicians had placed a temporary dialysis catheter in one of the large veins in her neck while another team worked on repairing her fistula, which had clotted again. Yet she returned to the hospital several weeks later with a severe pneumonia, likely caused by powerful bacteria she''d been exposed to during her last hospital stay.

When she finally left the hospital, she needed three weeks'' worth of physical therapy in a nursing home before she was strong enough to care for herself at home. Though she was able to return home, she struggled to dress herself, cook, or drive to her dialysis sessions every Monday, Wednesday, and Friday. She had come to the hospital today because a blood clot once again clogged her fistula. Her doctors wanted to place another temporary dialysis catheter and consult a vascular surgeon to create a new dialysis fistula alto­gether. But Donna said no. I don''t want dialysis anymore , Donna told her doctors . I''ve lived a good life. If Donna doesn''t want dialysis, her doctors wondered, then what does she want and how should we treat her? These were questions I had rarely encountered or considered in my years as a medical student.

Like the doc­tors who taught and supervised me, I was hardwired to preserve and pro­long life. On the few occasions I''d seen patients opt out of lifesaving treatments, I''d watched my supervising doctors struggle to articulate an­other plan-- and the consequences and limits of any plan at all. Donna''s team knew they needed help having that sort of delicate conversation with her, so they called the palliative care team to speak with Donna and help clarify what she wanted if she didn''t want dialysis. As it happened, I met Donna because I had chosen to spend two weeks of elective time on the palliative care service at the University of California, San Francisco, where I was finishing my last months of medical school be­fore beginning three years of residency training in internal medicine. I''d completed all of the required rotations to graduate, having spent one to two months each learning from teams of internal medicine physicians, gyne­cologists, family physicians, surgeons, pediatricians, psychiatrists, and neu­rologists. Now, in these last months of medical school, I''d been able to choose which medical specialties I wanted to learn, and which doctors I wanted to learn from. I searched the list of electives for inspiration. Medical school had been far more technical than humanistic, its emphasis heavy on the science of medicine, light on the art of doctoring.

In the first few years of medical school, I understood why this might be the case: I couldn''t diagnose and treat patients without an expert understanding of the body''s physiology, the ways disease could alter it, and the proper ways to treat the dizzying myriad illnesses humans suffered. Yet during my rotations, when I actually saw patients under the guidance of a resident and attending physician, I''d been struck by how little time I spent with patients-- to more than a few min­utes on rounds, and occasionally a few more minutes later in the day, when absolutely necessary. Entire days whizzed by as we ordered and waited for the results of lab tests and CT scans, typed detailed notes about patients into their electronic health records, met with social workers to figure out how to get patients home as quickly as possible, and talked with cardiologists and gastroenterologists about their recommendations for our patients. Caring for patients somehow meant spending very little time with them. One day, out of curiosity, I timed myself completing my assigned tasks. I spent twice as long in front of a computer as I did examining and talking to my patients. As graduation and the start of residency loomed, thoughts of quitting medicine arose unbidden in my mind. When I looked through the list of electives I could take, I was really searching desperately for reasons to finish my training.

I''d go on to spend a month working with a psychiatrist who specialized in treating patients struggling with substance abuse. I''d spend another month working with a child abuse response team at the county hospital. A classmate recommended that I take a two- week- long rotation with the palliative care team, and I found myself signing up for an elective with them, too. Donna was the first patient I''d see with Dr. McCormick, the physician on the palliative care team during my rotation. A handsome man with gen­tle brown eyes and a warm smile, Dr. McCormick wore a blue plaid shirt and khakis and worked closely with a social worker and a chaplain named Ellen. We sat together around a rectangular table and talked about each of the twelve patients our team was seeing, including Donna, our newest re­ferral.

"Sounds like the medical team wants to do what they can to help Donna continue dialysis, but she''s not digging that plan," Dr. McCormick said, summarizing the dilemma that Donna''s doctors needed us to address. "So let''s go find out what she''s got on her mind!" He was casual and person­able, professional but not distant. As we walked together down a set of hallways to Donna''s room, it struck me that Dr. McCormick had never met Donna before. I wondered how he, a stranger at the eleventh hour of Don­na''s life, would manage to earn her trust and ask her intimate questions that it seemed nobody had asked her before, including the many doctors who had been taking care of her since her kidneys began to fail. Sunlight poured through the window across from Donna''s hospital bed. I noticed her squinting and lowered the shade slightly.

Instead of hovering over her or leaning against the wall as she spoke, Dr. McCormick, Ellen, and I sat in gray folding chairs facing Donna. On the table next to her hos­pital bed, there was a brown tray with plastic rectangles of smashed peas, fluorescent orange carrots, and a small chicken breast. Someone had checked the boxes "low sodium" and "renal diet" and "diabetic" on a pink slip of paper taped to the side of the tray. "It''s dialysis food," Donna said, wrinkling her nose as she noticed me looking at her lunch. "Makes me more nauseated than my kidneys do." A copy of Chicken Soup for the Soul , many of its yellowed pages dog- eared, rested next to her untouched tray. Dr.

McCormick spoke to Donna in a soft tone that exuded compassion and presence. "We are from the palliative care team, and we''re just here to get to know you and to support you as you think through some of the deci­sions your medical team is asking you to make," Dr. McCormick said. "I need . all the support . I can get," Donna replied, her voice fading into a whisper as she made her way through her sentences. Donna''s fatigue penetrated her every word and attempted action. Lift­ing a forkful of green beans to her mouth had become an accomplishment, she told us.

She scratched her arms during our conversation, and dry skin flaked onto the blue hospital blanket. I had seen patients who looked as chronically fatigued and debilitated by disease as she did, but none who re­fused the therapies we offered, even when I wondered if they were strong enough to benefit from them. Dread had consumed Donna on the ambulance ride from her dialysis center to the hospital. She told us she had felt her heart thumping against her chest as though it were warning her of impending danger. She knew her doctors would offer her another procedure or surgery to fix her fistula and allow her to continue dialysis. But a question surfaced in her mind, one she''d considered from time to time over the past several months: Would a shorter life without dialysis be better than a longer life with dialysis? "I''m not suicidal," she whispered. "I''m t.