Guest post by Andrew Bomback
Doctors – at least the ones I know and respect – laughed at the “death panel” fears stirred up by opponents of Obamacare. The laughter stems from our near total impotence regarding death in the hospital. The patients and, more commonly, the families (because the patients are too ill and only rarely have clearly defined advanced directives) decide which life-sustaining interventions they want, regardless of medical advice. We can use leading language, we can make heartfelt recommendations, we can outright say that an intervention is futile or even inappropriate. The patient and the patient’s family ultimately make the decision on what to do and what not to do.
A 91-year-old woman was, according to her family, the “picture of health” until three weeks earlier, when she started to slur her words and lost her ability to use her left arm and left leg. She was taken to the emergency room, a stroke was diagnosed, and an ultrasound of her carotid arteries showed a clot that could be treated surgically. The post-surgical course was complicated by a heart attack and, a week later, kidney failure. I was asked to talk to the family about dialysis.
“If we put her on dialysis,” I said, “she won’t die of kidney failure, but she will be dependent on a machine with very poor quality of life. She will still die – maybe of heart failure, maybe of infection. All the dialysis does is change the cause of death.” I was using leading language. I did not feel that dialysis was the right option. It helped that two of the three children of this 91-year-old patient were physicians. I would have used softer language with non-physicians, and I would have felt frustrated with that kind of language.
“It sounds like you’re recommending against it,” the oldest child, a gastroenterologist, said.
“Look, the way this works, as I’m sure you know,” I answered, energized by the opportunity to speak honestly about a dying patient, “is I can give you my recommendations, which in this case are not to pursue dialysis, but ultimately the decision is up to the patient, and when the patient can’t decide for herself, then the family makes the decision. So, I can tell you not to do dialysis, but if you say you want dialysis, I’ll do it. And when I leave this room and place the orders for dialysis, I’ll feel like I’m doing the wrong thing.”
This frustration begins as early as medical school and residency, as soon as trainees are exposed to the grim and prolonged dying processes that regularly occur in American hospital. When I was a resident in the ICU, there were families that frustrated me and my co-residents in their steadfast refusal to accept a patient’s imminent death. Every day we asked them to make their family members DNR/DNI – don’t force us to do CPR or intubate those who are essentially dead already – and every day they refused. When those patients coded, the codes were run with the curtains closed, with the least amount of effort possible. We acted with less urgency than we would in a practice drill. We whispered instructions to the nurses. We did chest compressions with the tips of our index fingers.
“What are all these dead people doing in my ICU?” My favorite pulmonologist from residency used to start her attending month with that question. We’d laugh, but she was serious. After rounds, after we’d relayed all of the morbid details of each patient, she’d go from room to room, family to family, and by the end of the morning, half were transitioned to “comfort measures only.” The transition to a peaceful, dignified death could finally begin.
We idolized this pulmonologist. We called her by her initials – L.P. – and when another attending ran the ICU, when under his or her supervision we flogged and flogged and flogged, we consoled ourselves by saying, “L.P.’s coming on service next week, and then we can stop.” We loved L.P because she appeared to be utterly objective about patient death. And we needed to show her this love because, by the time L.P. arrived in the ICU, we’d typically be less than objective about the same patients. After so much flogging, we were actively rooting for patients to die and end their suffering.
Andrew Bomback, MD, is Assistant Professor of Medicine at Columbia University College of Physicians and Surgeons, USA. His writing has appeared in The Los Angeles Review of Books, The Atlantic, The Kenyon Review, The Millions, Vol. 1 Brooklyn, New Delta Review, Essay Daily, and Hobart. His new book, Doctor, is part of Bloomsbury’s Object Lessons series.