Tuesday, October 7, 2008

Before Dying, Leave Word

To cure sometimes, to relieve often, to comfort always.
-attributed to Hippocrates (460-370 B.C.E.)

There are families who accept death with peace, dignity, and an unselfish regard for their loved one's wishes.

There are other families who cling to the one they love, and want "everything done" for the person, not because that's what their loved one wants, or would benefit from, but because they, the family, aren't ready to say goodbye.

And there are a whole lot of families who struggle in between these two responses in a morass of confusing emotions and data, with a situation that is nowhere near black-and-white. Many, many cases probably fall into this category.

The second response to the dying process is a challenge for clinicians who are caught in the middle. We sometimes feel trapped into doing things against our own wishes, against what we sense to be our patient's wishes, and against what we feel is medically (and in other ways) right, only because the family has legal say.

I was called in the middle of the night to intubate a man with dementia who was almost a hundred years old. He had been admitted to the hospital with respiratory distress and intubated several days prior. He yanked his own breathing tube out, and for a couple of days he tolerated life without it. But the night I was called he had taken a turn for the worse. His carbon dioxide level was in the triple digits, appallingly high. The family could not be reached for discussion and had previously indicated they wanted invasive interventions (such as the initial intubation).

Normally, getting asked to do an intubation in the ICU is one of the most satisfying parts of my job. I feel like I'm being asked for help because I can do something no one else on the medical team can (comfortably, at that particular moment, in that particular hospital), at least not with the same expertise, and the task is potentially life-saving. It's also my favorite anesthesia task in general. I enjoy intubating.

But this one made me terribly sad. The nurses told me that between the last intubation and this one he had said plaintively, through the cloud of dementia that was robbing him of his rights to make decisions for himself, "I'm tired. Please let Jesus take me." So why were we doing this? We felt our hands were tied.

The author of The Choloroform Rag said it well: "Watching someone posture and contort, be maintained on machines, and receive multiple medications through large bore IVs and central lines is an awesome spectacle and testimony to the advancement of medicine; but it's wrong. We know when Death has arrived. Wanting 'everything' to be done to keep grandma, mom, dad, brother or whomever alive simply because we can't accept the fact that Death lurks in the room is destructive."

Please don't do this to your loved ones at the end of their lives when aggressive medical intervention cannot improve their quality of life. Please let them go, peacefully, if that's what they want. Have a plan for the end, as RuralDoc suggests. And trust that even when treatment and cure lie beyond reach, the clinicians involved still want to provide "comfort always."


rlbates said...

Couldn't agree more. Take care, T.

Anonymous said...

This raises issues of consent. I don't know exactly what the legal perspective on those things are where you practise.In UK this patient would have DNR order put in place and he would never had been accepted for an ITU bed.

Here family has no legal power to consent for treatment or demand treatment on behalf of the patient. If patients is not comepetent to consent physicians are expected to act in patient best intrest taking families opinions into consideration.

I used to wonder if decision making should be left to families but stories like that make me think that it is better if doctors have the last word in deciding who is an ITU candidate and who is not.

Resident Anesthesiologist Guy (RAG) said...

Thanks for the reference. I think I'll be submitting the post you referenced to grand rounds as it's something I'm getting more and more experienced with and irritated.