Friday, March 1, 2013

end of life care (and growing some balls)

Lately, we have several end-of-life patients for whom we can no longer treat, that is to say, despite all of our treatments or therapies their prognosis will remain poor and their death is imminent. This particular group is frustrating to all of us working in the ICU, because each of them are being kept alive by our machines (or their dying is being prolonged, you could say), because the family members or even the patient themselves are in denial.

Case #1: This patient has cancer that has spread to many organ systems and is no longer responsive or able to tolerate chemotherapy or any other type of aggressive treatment. Her oncology prognosis is extremely poor... as in, she only has a limited time left to live. Naturally, because we are supporting her on a ventilator, she is living a little longer. But she is very weak, unable to communicate, and she's suffering. Her children insist that she would not want to be kept alive like this, but her husband is unable to let go. He looks for any little positive thing as "progress". He doesn't want to make that decision, the decision to withdraw.

I so get that. When I was in labor and complete, I did not want to be the one that pushed my daughter into the world knowing she would not survive. I knew it was the inevitable outcome, but I did not want to be the direct cause of it! This poor man does not want to make this decision... in this situation, most of our attendings or fellows step in and gently but firmly say, "we've done all we can. We have nothing more to do. It's time to make a decision".

The attending this month is just plain awful. He has let the patient continue to deteriorate while orally intubate for almost a month now. Family meetins are ongoing, but he refuses to draw a firm timeline with the family. In short, he won't let this husband off the hook. He won't make the decision for him, or help lead him to it. This poor husband feels that he is all alone in this choice, and meanwhile his wife, the patient, suffers. It's absolutely terrible to watch.

Case #2: The CFer I mentioned in the last post has been failing for weeks as well. This case is quite different in that it is the patient who is making the decision to prolong his own life. He's still mentally capable of making all of his own decisions, but he is just too afraid of death to withdraw on himself. It's hard to watch, but understandable. The worst thing, though, is how this particular attending comes in in the morning and says things that could almost be perceived (by a very scared patient) as hopeful. It's awful. In this case we are complying with his wishes, but the attending is not helping the situation. The fellow did a much nicer job, later, of explaining to him that we can keep him comfortable, or can continue aggressive vent management that may prolong his life for a short time but may make him uncomfortable. At least with that information he can make an informed decision.

Heavy stuff, always. There are just some doctors who really know how to go about end of life care with the right mix of compassion and firmness, and some who shy away from it.

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