When to Let Go

Unfortunately, far too many children in our area are dangerously malnourished—a condition that can lead to a weakened immune system, serious co-infections, and death. Our clinic has a re-feeding program for such malnourished children. We receive UNICEF-provided formula and medications that are specifically designed to help malnourished children gradually gain weight and build their immune system. Most of the children we treat recover quickly—an achievement that is extremely satisfying to watch. But this morning I discharged a malnourished child who had not gotten better—a heartbreaking and painful decision. This 3 year-old girl had been in our malnutrition program as an inpatient for a month. In addition to the formula feeds, we treated her for intestinal parasites, bacterial infections, checked for malaria and HIV, and even started tuberculosis therapy (which should now last for 8 months). But she still has little appetite, and she weighs 2/3 of what she should weigh for her height.

In the U.S., I was trained to do everything for my patients—to think about all the possible diseases, diagnose the appropriate illness, and treat accordingly. I was spoiled into thinking that with enough resources, tests, and consults we can uncover an answer to even the most difficult clinical questions, and treat (and fix) the problem. I was taught to never give up. Here, I am learning very different lessons. I am learning that with limited resources comes limited capacities. I do not have specialists on consult, and I can’t send everyone to the university hospital four hours away if I have questions. But more importantly, I have to respect the desires and limitations of my patients. Families here face decisions that most people in the US are lucky to avoid—to save one child or feed the rest; to spend everything they own to travel to a hospital where their child will most likely die, or take them home to be with their family.

Today, I had to respect the wishes of a father who could not spend another month with no income and a family to support. He looked at me this morning and, via a translator, said “thank you…thank you for all your work to try to help my daughter. I know that she may die, and I am very sad. But I need to go home.” And without a diagnosis, without an answer, without succeeding in helping his daughter, I went against my American instincts and let her go.