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?