Saturday, August 15, 2009

End-of-Life Preparation Is a Responsibility, NOT a "Death Panel"

"Anesthesia, STAT to Unit Five.  Anesthesia to Unit Five, STAT."

I bolted up the stairs and then down a long corridor.   The room I needed to find was of course the very last one.  Just outside the doorway a woman with greying hair stood weeping, and beside her a younger woman was wringing her hands.  Beyond them I saw a male patient lying on the bed.  A man in a white coat was performing chest compressions.  Another man in a white coat stood at the foot of the bed managing the code.  There were a respiratory therapist and two nurses assisting, one to record data, another to fetch and push drugs.

The man at the foot of the bed turned and saw me.  "Good, the anesthesiologist is here."

He turned to the two frightened, distraught women in the doorway.  

"If we're going to continue with the resuscitation, we need to get a breathing tube in.  May we proceed?"

The bewildered women turned to each other.  "What?  Um, I don't know.  I don't think he wanted that," said one of them.

"Yes he did - he said we should do everything," said the other.

"But he told me he didn't want to linger on machines..."

Meanwhile, the doctor and nurses in the room were trying to get our attention.  "We need to intubate him now." 

The first doctor turned to the women once again.  

"I don't know, I don't know!"  they said, with panic in their eyes and voices.  

I started preparing equipment and drugs, but eventually, the family decided against continuing the resuscitation.  They sent me away.  The other doctors and nurses stopped what they were doing.  The patient died.


It's because of situations like this that I cannot believe, absolutely cannot BELIEVE, that anyone, solely for political scare-mongering, should be so misleading and ludicrous as to attack the idea of end-of-life counseling - especially considering the fact that the proposed counseling is VOLUNTARY.  

Frankly, as a physician I actually think it SHOULD be mandatory rather than voluntary.  Too few families are prepared for their loved ones' impending deaths - the decisions that have to be made, the ability to respect their loved ones wishes.  How can families make sound decisions if they are completely uninformed of the choices they have?  
The House bill requires "an explanation by the practitioner of the continuum of end-of-life services and supports available."  It is insulting to the public's intelligence to try to propagate the idea that the government is trying to end people's lives sooner simply by proposing the means by which to educate the public about their options and to encourage dialogue both among family members and between health care providers and families.  How can doctors and nurses provide the care and service patients want if patients haven't reflected on their own wishes and made them known?  

I mean, are people like Palin, Grassley, and Isakson really that obtuse, or are they just faking it, twisting the truth or downright making stuff up, for ideologic reasons?

Health care is ALREADY rationed.  It's called being DENIED health insurance claims for things like cancer surgery, denied coverage because of a "preexisting condition," and the like.  While we might complain about the details and be concerned about the funding, we really shouldn't be complaining about the idea of making health care more AVAILABLE.

The woman who is worried that people over the age of 65 are going to be "told to decide how they wish to die," and others like her, should realize that that's EXACTLY what they should be thinking about and working on, for their own sake and the sake of the loved ones and caregivers who will be part of that final journey.  Artificial feeding or not?  Breathing machines or not?  Comfort measures only, or full invasive resuscitation, including cracked chest and internal cardiac massage?  People SHOULD decide as best they can how they wish to die.  They should then make their wishes known as clearly as they can, both to their families and to their physicians.  Then their FAMILES in concert with their PHYSICIANS, NOT their insurance companies, should come to some final decisions together. Maybe then they can actually have a chance at exiting this life with the peace and dignity that each person hopes for and deserves.


Dalilah said...

Go tell it on the mountain T.! I agree with you totally! We all need to be prepared.

Bleeding Heart said...

Great post. I wonder how often as an anaesthesiologist, I have been complicit in prolonging someone's life against their wish.

Old MD Girl said...

Aw, T. Of course they're making it up! It's all the same old politics we know and love.....

Re your post: What a horrible decision to have to make at the time of your husband's code! Well said.

T. said...

OMDG: to clarify, it wasn't my husband coding, but probably the husband of one of the women in distress in the doorway. If only it had been MY "horrible decision" instead of theirs - my instincts are always to "intubate now, ask questions later..." Makes things simple for me, but I know it's really not that simple.

Old MD Girl said...

Ah, I should have said, "one's" husband's code.

Thanks for the clarification, though.

rgk said...

I thought that once a person is intubated it is not legal to remove the tube without a court order... this assuming that the patient is not conscious and did not leave clear, legal instructions about end of life choices.

Is that true?

KC said...

I love this post and agree with it 100%, T. 100%.

kennyrrt said...

Everywhere I am aware of, if family or power of attorney and the doc agree, life support can be d/c'd without court involvement. In cases of no POA or family, a guardian must be appointed.