The coffee contract

The coffee was mediocre at best, poured from a sitting carafe into a generic Styrofoam to-go cup, and shared in a sterile-feeling room without a view. But, for this man, this cup of coffee was worth risking his life. It was more than a decade ago, and I was an intern rotating at the Veterans Affairs hospital, each morning prerounding on my 50-ish-year-old patient dying of throat cancer. I always found him lying in his hospital bed alone and quiet. He had lost the ability to safely swallow, at least that is what the speech therapists and doctors kept telling him. He now received all his nutrition, an unnatural-appearing tan liquid, administered through a percutaneous gastrostomy tube. He was wasting away. He no longer had the strength to walk on his own. It felt like he was slowly just disappearing, one day he would simply be too small and too quiet to even see. Were we really doing right by him? Was I practicing humanism, or merely just "medicine"? As a diligent intern, I was focused on all the details: making sure his potassium and magnesium hit the marks, documenting "temporal wasting" in the medical chart, and treating the acute medical issues that inevitably popped up as he spent these days in the hospital. On prerounds, he was a checkbox. One that I could cross off rather quickly as the details settled in, and the amount of active management required each day shrank along with his physical body. There were always lots of patients to see during these busy mornings and I prepared for rounds with our attending later that morning. Should I not prioritize? Triage? Then one day, when I realized there really were not any other checkboxes to complete for him, I finally asked what was important to him and what else I could do. I do not remember for sure, but I bet I had a travel mug of coffee in my hand. "I just wish I could have a cup of coffee," he told me, as I once again found him sitting awake and quiet and alone one early morning. "Just to taste coffee once again." My knee-jerk intern reflex kicked in, "I wish for that too, but you cannot have anything by mouth, it's dangerous, I'm sorry." He winced, "I know." I left the room feeling that my question may have done more harm than good. I kept thinking about that cup of coffee. We talk about patient centeredness, but what does that really mean? My patient has not once worried about his potassium level being low, but I focused more on his potassium levels than whether he could safely drink a cup of coffee. How should I prioritize? Triage? Patient autonomy was taught as one of our medical ethics in medical school; yet, it was hard to see how that was practiced in the hospital where we "order" what people can eat and do. Perhaps, this was just another noble ideal espoused in the classroom that didn't translate when we hit the real clinical world. Fortunately, for both my patient and me, my attending that week was a geriatrician who possessed a wisdom I lacked about some of life's big pictures. I brought up the cup of coffee, and she helped me talk through it. I expressed my concern that he was going to aspirate and die in front of me. "Maybe, that could happen," she said. "It is a risk. Does he understand that?" "Yeah, I think he does, but he wants to try anyway." He already was clear that he did not want to be resuscitated in the event of cardiopulmonary arrest; he knew he was dying. There was some more gentle back-and-forth and my own hand wringing over the issue. I was worried that if something bad happened, the institution would come down on me. The patient had a long-standing order for nothing by mouth. If I—the doctor currently taking care of him, sure, but also an intern without a track record of outcomes or a reputation to lean on—overrode this order and gave him coffee, certainly that would be a problem for me. To her credit, my attending did not offer to rescue me from this dilemma or to put all the responsibility onto her shoulders. Then I said something like, "What if I create a written agreement that he understands that he could 'choke' on the coffee and that it could cause pneumonia and he could die from it but that he understands the risk and wants to have this coffee anyways for his comfort and goals?" My attending suggested I should try it and that she would have my back. I pulled out my intern to-do list and created a checkbox for a coffee contract. My patient and I sat and talked that afternoon and I let him know I wanted to respect his wish and would love the opportunity to sit and drink a cup of coffee with him the next morning. "That would be nice," he simply replied. I could tell he thought it was a little ridiculous; of course, it was; yet, he dutifully read and signed my "contract," and I then marched over to medical records on the other side of the VA, searching through hallways I had never explored, and asked to have it uploaded into his chart. The next morning, we drank coffee together. The first few sips had me terrified. I tried to exude cool calm while my insides were aflutter, like the old saying about the duck furiously treading water just below the surface. He sipped cautiously. I could tell he too was scared. As he slowly swallowed each small sip, our nerves settled down. And, as is natural when sharing a cup of coffee with someone, we began to chat. He told me a bit about his life, and I asked about his service in the military. I learned so much as the coffee noticeably warmed the cold San Francisco room. It took me a while to crystallize some of the lessons of the coffee contract. I thought about this experience when I flew out to New York in 2021 to see my grandmother for the last time. Despite my calls for days beforehand to speak with the medical person in charge, I was unable to enter the building nor have my grandmother meet me outside in the courtyard. I tried to explain that we were both vaccinated and could test and could wear masks (heck, I could even wear the same equipment I use to safely care for patients with COVID-19 in my own hospital) but to no avail. We spoke through a closed window, and I blew my grandmother a kiss. The protocol was the protocol. As Atul Gawande poignantly describes in his book "Being Mortal," our healthcare system is set up to always maximize perceived safety; yet, there is an importance in balancing safety and independence.1 If the system and protocols will always throw their entire weight onto safety, then we are the only ones that can help balance the scales. We alone can bring the ideals from our classrooms, such as autonomy and shared decision-making, into our clinical settings. Systems cannot care. I have never again written this type of coffee contract, nor have I asked a patient to sign one. I learned that I can have shared decision-making with my patients, and we can openly discuss risks and benefits without the need to upload contracts. It does not happen often enough, but over the years, I have shared a slice of birthday cake with a cancer patient who had a carbohydrate-controlled diabetic diet order. I have taken moments to sit and eat hospital ice cream, the one with the wooden stick spoon, with my patient who had been hospitalized for a month. I have reminded myself that a shared moment over ice cream, or a mediocre cup of coffee, could be more therapeutic, for both of us, than anything on a medication list that day. I have learned that my role, through practicing humanism, is to balance the defaults of the system and focus on what matters, even when that is as simple as a cup of coffee. The author declares no conflict of interest.