Monday, October 31, 2011

Respect for Death

In a way, it's apt that I'm writing this post on Halloween, even though this event transpired about 4 days ago.

I had been following this one patient ever since we admitted him to the hospital from the clinic towards the beginning of October. He came to us after seeing many other doctors, all of whom had failed to solve his problem and relieve his pain. We promised him that we'd try, that perhaps we could finally release him from his suffering.

I had checked in on him every morning before the team, at the crack of . . . well, evening (since it was well before dawn). I saw the misery he was in every day. After the first week, we had identified the problem - an infected bypass graft in his leg. We operated and removed the graft. As a complication, a clot was "thrown" down to his foot causing his foot to become ischemic (lack blood flow) and die. We operated and amputated his toes. Every morning I changed his dressings when I rounded with the team.

We assured him that we had fixed his problem, but he was still miserable. Every day we prayed that he would get better. He wasn't getting worse, but he wasn't progressing either - just stayed in that limbo where he wore a pained mask. Last Thursday, my resident remarked, "He isn't getting worse but he's also not progressing. If he doesn't get out of here, he will die here." I changed his dressings as he waited patiently to watch The Price Is Right on TV. To me he had looked better than he had that entire week.

That afternoon I got the call that he had coded. He had a seizure or a stroke or a heart attack, no one was really sure. The resident did CPR on him for 20 minutes before the surgeon found a pulse. He was wheeled off to the SICU (surgical intensive care unit). One thing was for sure, he was in bad shape. Later he was found to be in PEA (pulseless electrical activity). He quickly approached the threshold beyond which treatment would be futile. After discussion with the surgeon, his daughter made the decision to withdraw care and at around 8:30pm, he died.

The following morning, the other med student and I stalked his chart to figure out why he had died. When he had read that his daughter made the decision to withdraw care, he said out loud, "What?! She withdrew care? His family killed him!" That infuriated me. He was in that zone where we could keep him technically alive but without any quality of life. To me, his daughter had saved her father from a week of agony in a state of painful limbo - neither truly alive nor dead. That afternoon as we briefly discussed about him, the surgeon agreed that the daughter had done the right thing. She had saved him from a miserable pseudo-existence, a kind of hell on earth.

One of the most important things to learn is when not treating is the correct treatment, and when we should respect death rather than fight it. This goes against almost everything we've been taught and trained to do. We must always keep in the back of our minds whether or not aggressive treatment is worth it, especially in absence of a cure. The figures don't lie: we spend most of our health care spending in the last 6 months of life. Why? Because for one reason or another, we just can't let go when we really should.


Raymond said...
This comment has been removed by the author.
Raymond said...

Well if you would look at bioethics, his daughter just made the better choice. There just things that we from the healthcare field are not in control of. It's frustrating really but we need to examine ourselves and the situation keeping the best for all parties as our main interest. :)

Biki said...

There is a time where life isnt the same thing as being alive. And your Mr. B wouldnt have a life, only be alive. There is a big difference, and some people just cant see that. It could be that your Mr. B just gave up, was tired of fighting the non-stop round of pain and being mucked about with doctors and nurses and whatnot.

robert said...

" Why? Because for one reason or another, we just can't let go when we really should..."

Denial of death's inevitability is a powerful pursuit for many. It is difficult to hear such stories. Anyone who is experiencing
excruciating pain is unable to appreciate life in the same moment as the pain. Unfortunately, the choice to die is rarely available to the suffering.

. said...

Very nice writing Aek, as always it's thoughtful and well written and insightful into a world in the medical profession that so few people see. I'll say it help bring out the human side of medicine. You care and it shows!! Have a great week!! I'll chat with ya soon!!

R said...


your fellow med student

had a substantial douche moment there.

naturgesetz said...

Sorry I missed this when it was new. Anyway, it occurs to me that we have a mindset that fit an earlier stage of medicine — when interventions were not so drastic as they now can be, when once a person's heart stopped beating there was nothing more to do. From that earlier time comes the attitude that if something can be done, we should do it. Our ethics always have to catch up with our technology: the fact that we can do something doesn't always mean that we should, or even may, do it, but it can take a while to think it through.

naturgesetz said...

BTW, did you figure out why he died?