On Death

United States is one of the unique healthcare systems in which the physician is not allowed to sign off on a patient as medically futile. Here, it’s “do everything you can” to save a life, regardless of the subsequent outcome, complications, or quality of life. It seems odd that in the face of modern American medicine, the focus has shifted to quantity of life instead of quality.

At what point do we cease these invasive and damaging efforts to resuscitate someone who may no longer be salvageable? At what point do we cross the respect the loved ones’ desires and guilt-fueled motivations and lay down the futility of such acts? At what point do we play the judge of “a life worth living” and trusting that loved ones will act in purely in line with the patient’s desires?

These are difficult questions to answer. As fellow human beings, it is understandable that we may be affected by our relationships in decision making. What loved ones want may not be what patients actually want. Instead, it may be an attempt at redemption – patching up tears in relationships. In the end, are we taking action to save the patient’s lives or are we taking action to ease loved ones’ heartache?

In the early hours of morning rounds, one of our patients started decompensating acutely. She had been estranged from most of her family and was living in a nursing home prior to her hospitalization. A failed central line had resulted in complications that acutely threatened her life. We started placing another central line on the left side, but it was proving to be difficult. As the fellow and attending worked on this procedure, they discussed whether the patient was likely to survive this and what other procedures she may need. It was agreed that she may be on hemodialysis permanently after this, and the fellow left to inform the family.

At first, the family had wanted everything done, and we proceeded with the difficult central line placement. As her condition worsened despite its completion, the attending felt that she would not survive this acute illness, and even if she did, there would be very little quality of life. They reconvened, and there was discussion that perhaps the family needed to see what state she was in. I wasn’t there for the conversation with the family, but eventually they decided to let the patient pass without pursuing any more invasive tasks. As we continued rounding, I saw them from the periphery of my eyes and noticed three women holding hands in a circle praying. They stood there quietly for some time, and then they eventually came up to us and thanked us for letting her pass peacefully instead of prolonging the struggle.

In some parts of my mind, I wondered if our efforts should have been more focused on conveying the gravity of the situation with the family instead of trying to place the central line. From the start, her prognosis was not good, and the difficult placement only made the situation uglier. The impression that things were going to be done created a false sense of hope, and the uncertainty of the patient’s outcome led to the silence of her impending death. I think, if we had been more honest, maybe that conclusion would have been reached earlier. The fear of paternalism is very real here, and it was a juggle of time between saving the patient’s life and laying down the hard facts with the family. In these acute settings, there is no time to call the social worker or palliative care to talk about the separation of guilt and respecting wishes. There is no time to psychoanalyze the choices loved ones make in lieu of our patients. There is no time to weigh which one is a better choice: aggressively saving a life or having an in depth conversation with the family. Often, both is done in attempt to cover all bases.

It’s a strange notion, then, that most of us in the career of medicine do not wish this upon us. Too many times have I heard physicians or residents tell their loved ones that they don’t most things done if they decompensate. Knowing the procedures done and the grave aftermath, most of us do not want a potential life of severely diminished quality of life. It’s strange then, that we don’t convey this to our patients and their loved ones when it comes to deciding time.

Is it because we have seen too much? So much so that we think that when we are that ill, such suffering is not worth the risk? Is it because we’re afraid to break such finality? To aid in such a permanent decision that may result in irreversible regret? We know that we would not want this for ourselves because we know ourselves and our loved ones, but we don’t feel comfortable making that decision for others. Is it fair to allow them to not know better and make decisions without fully knowing the potential outcome? As physicians, we are trained to deal with not only life, but also death. While we have the responsibility to save lives and heal ailments, I believe we also have the role to guide out patients in the process of letting go.

That when the time comes, we know how to place quality over quantity.