How far do you go when no matter what you do, the patient's going to die?
We have a woman with end-stage cancer, in terrible pain, barely responsive, does not have a lot of time left, will never have any quality of life, will die either here or in a nursing home, no upside potential here-- it's sad, she's sick, she's dying.
At the same time, she has a gangrenous infection in her leg that's spreading quickly. In a healthy patient, we would absolutely have to amputate the leg, now.
The infection will kill this patient, most likely before the cancer will.
But it's crazy to think this woman has much of a chance of surviving the surgery-- and even if she does survive, she's not going to do well post-op, certainly she's never going to get out of bed again, and post-surgery she'll be in even more pain than she's currently in.
So what do we do?
Keep in mind, there are no good answers here. Not amputating her leg will kill her. Amputating her leg might buy her a couple more weeks, but they'll be painful weeks with no light at the end of the tunnel, and there's a good chance the surgery won't end up buying her any time at all, because she'll die on the table.
Her family has no grasp of the reality of the situation. They want us to do "everything we can."
In other words, they want the surgery.
And the surgeons are happy to try and do the surgery-- they legitimately do want to help this woman, and not doing surgery means she will certainly die.
So every day the surgical team comes in to evaluate her. Is she stable enough? Is she more responsive than yesterday? Is she moaning quite as loudly? I don't know quite what they're looking for-- she's in terrible shape, she doesn't answer to her name, she barely opens her eyes, it's absurd when I hear the resident tell the attending, "oh, she's looking much better than yesterday-- she's not quite so curled up into that fetal position like before."
She is going to die no matter what we do. We are torturing her. But if we don't do the surgery, we are killing her.
There is no good answer. There is just a very ill woman who is unfortunately going to die. And I suppose if it were my mother, I'd want her to have the surgery-- anything to buy any amount of time, any chance for a miracle. Except I think I'd be wrong. I think I'd be completely wrong.
Would you want the surgery? Can you even justify the surgery? But-- assuming it's not taking away from someone else's chance for surgery-- how do you justify not doing everything you can?
Thursday, September 3, 2009
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How do you justify not doing everything you can? I think it's about the ultimate goal, not about the steps that lead you there. If she had a chance of survival, or better quality of life, you would amputate the leg. But, it doesn't. She is going to die. All you can do is make her suffering more bearable (or less unbearable), so IMHO that means pain medication, maybe sleep medication so she won't feel it.
ReplyDeleteIf she is going to die anyway and is not communicating/awake, what's the point in prolonging her suffering?
if i were the patient, then i would not want the surgery. but if i were the relatives, i would want to try everything i could, just to keep her alive for that little bit longer. its a very difficult situation, because no matter what you do it is wrong to someone.
ReplyDeleteMy background is Public Health, not Clinical Medicine. You justify not doing everything you can by noting that it would be absolutely fruitless.
ReplyDeleteYou state "no matter what you do, the patient's going to die [soon]." Also, "anything to buy any amount of time, any chance for a miracle". The first statement is a clinical judgment, and the latter is a perfectly human but irrational hope. As a physician, I believe you would ultimately forgo the surgery even if it were your mother. EVEN as a physician, though, you haven't quite let go of the irrationality --- so how could a family let go? They are not emotionally capable of making a rational, even humane, decision.
As a matter of policy, then, either families have to be manipulated to the conclusion (ethical? feasible with the surgeons offering their biased 2 cents?) or the decision has to be taken out of their hands. The former happens all the time, and I would have to say it's justified. The latter would require an explicit recognition that rational public health decisions WILL be made, and I don't think we will ever come to that. Since we don't have the courage to face reality, either as individuals or as a society, it's going to continue to fall on you, the clinician. Good luck!
This is a great case for a living will and the advance counseling that is suggested in the health care reform bill - the part that has been so inaccurately called "death panels." My father-in-law had several "curable" maladies when he entered the hospital recently. Thankfully, he and the family had prior counseling and were in agreement with the patient's wish to not undergo extreme means to prolong his life. So when he was in the ER with most of his bodily systems failing, his wife said, "Please just make him comfortable." The doctor was empathetic and honest. "You know this means he is going to die," he asked. We all knew the answer.
ReplyDeleteHe had been existing miserably in a nursing home for about a month prior to this incident. The doctors told us they could treat the three or four things that combined to put him in the hospital this time. He had been in the hospital several times over a period of six months, including a week in the intensive care unit. Because we had talked about it, we knew his wish was to let him go, not to extend his life of pain and misery even though it was medically possible.
Thank goodness for the counseling.
I would hope you'd give her enough pain medications that she's not moaning in pain all the time. Seriously.
ReplyDeleteMe, personally, I hope I'd eat a bullet before I got near that point.
As much as people love to mock the idea, this is why we need bean counters rationing medical care. How much money is wasted every year on these frivilous treatments? I'm sure the amount is staggering.
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