Recently I found myself in the intensive-care unit perched above a 91-year-old man plunging a large needle into the side of his neck in order to place a catheter into his jugular vein.
The catheter would wind its way toward his heart and allow us to infuse medications to bring his blood pressure up. For a physician, this can be an incredibly satisfying procedure, but in this case I could not slow the refrain in my head that told me, “You are torturing this man.”
As a physician, I frequently confront situations like this. A patient nears the end of his or her natural life, and I am left wondering whether the lifesaving treatment is helping or hurting.
When I met the patient and his family in the emergency room, I heard a familiar story: the slow ravages of dementia, the falls at home, hospitalizations for pneumonia and most recently a broken hip.
Pain medications had made him confused and agitated in the hospital a week ago, so he was taken off them and left to writhe in pain at a nursing home where he ostensibly was undergoing physical therapy to get better.
I took the time to ask his family about him in better days. He had been a proud man, served in the Pacific during World War II, raised four children, saw his wife of nearly 60 years through cancer, then death.
He looked close to death himself – eyes rolled back, mouth agape with dried spittle and blood at the corners, his breathing shallow and fast. His chest X-ray was almost whited out, suggesting a combination of pneumonia and fluid backed up from a failing heart.
I laid it out to the family in no uncertain terms. Their father was dying. If we pursued an aggressive course we would need to intubate: insert a large tube down his throat into his trachea and allow a ventilator to breathe for him.
Alternatively, we could make him comfortable using sedatives and pain medications to ease the struggle of not being able to breathe. They wanted us to do everything to keep him alive.
The patient, who had been almost comatose in the emergency room, was now awake, restrained, his eyes wide open in horror, head jerking side to side as I inserted the needle into his neck.
We had tried our best to ease his pain with medications, but even the smallest doses would dangerously drop his blood pressure. I was doing everything I could to keep him alive. Broad-spectrum antibiotics had been given early, his oxygen levels had been improved by the ventilator, IV fluids and vasopressor drugs titrated based on validated studies of septic shock.
Yet it was clear to me that I was depriving this man the chance to die a comfortable, dignified death. I was failing him.
In August, the Care Planning Act of 2013 was introduced to committee in Congress. The Care Planning Act would provide incentives to primary-care physicians to engage in voluntary discussions with patients surrounding end of life. It would also help spur a public information campaign encouraging everyone to conscientiously plan for this inevitable part of life.
A similar bill was removed from the Affordable Care Act after pundits embarked on a misinformation campaign, equating end-of-life dialogue with “death panels.”
As this new bill is considered, it behooves all to examine our society’s discomfort with the one fate that we cannot escape. It almost feels, at times, in the crush of technology and medical advances, that families have come to consider death an elective procedure, that can be held at bay indefinitely.
Will this bill transform how our society deals with end-of-life issues? Probably not. But it is a good start. Waiting until the brink of death to decide how to negotiate your final days rarely works out.
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