Saturday, April 5, 2014

Comment on "How Doctors Choose to Die"

This reminds me of one of my last nights in residency. (Details changed to protect privacy.) As I signed on, I saw that I would be responsible for a very sick, 100-year-old man. I had a sinking feeling that he was going to die that night, and, if he did, I would have to do horrible things in a fruitless attempt to bring him back. He was demented and unable to speak for himself, so I told the family what I thought might happen. I asked their permission to allow him to die if it came to that.

They refused. He was from a foreign country, and his family mistrusted our medical system, since, where they were from, doctors had abused people like them. They weren't about to let a man in a white coat stint on their venerated grandfather. So I went to the call room and tried to sleep, fearing the inevitable beeper interruption.

A few hours later, it came. The 100-year-old man had stopped breathing, and his heart had stopped. Someone had 'called a code.' I came downstairs to find my team around his bed. Looking at each other sheepishly, the interns, nurses, and I stabbed him with a large needle to place a central venous line, pounded his brittle ribs, and shocked his withered heart into a few more beats. As I jammed the endotracheal tube down his throat as gently as I could, his dying eyes glared at me, and his face contorted in a rhythmic, reflexic scowl of brain death. His heart stopped again. Finally, I decided we had played the charade long enough. I pronounced him dead.

I cannot dismiss the effect the family's collective history had on their priorities. Perhaps there was no other way for them, but, to me, this whole effort had been a horrible crime.

Calling a code is not always pointless. Chances of survival are bleak, but a previously vigorous person who makes it through a code has a reasonable chance of walking out of the hospital on their own two feet and in good mental shape. On the other hand, once someone is frail and fatally ill, cardiac resuscitation is practically useless.

Resuscitation for all cardiac arrests is still the default in fact, though not in law (at least in my state). This is for bad and good reasons. Doctors are afraid of lawsuits, and some salvageable lives have been forsaken out of prejudice or base motivations. A family's wishes cannot be dismissed lightly.

But, if you don't want this to happen to you, please plan for this. If and when you are fatally ill, make sure everyone in your family understands that you want to go peacefully when it is time. If you don't, some prodigal son might return and demand that everything be done to 'save' mom to assuage his own guilt. Or your spouse, not knowing your wishes, might be unwilling to deny you the 'best' care. Give them permission to let you go.


  1. Tom, what is the best way to make sure my end-of-life wishes are followed? I know that a Living Will is helpful, but if I come into an emergency room how will those doctors know my wishes? Thanks for your medical expertise, as a total layman, I am always "taught" by your messages. :-)

  2. Hi, Ol' Texas Gal,

    In my experience, these awful situations usually do not come up as sudden, unconscious and anonymous trips to the emergency room, but it is possible. Always carry something on your person that is easily identifiable and clearly shows how to reach your next of kin and an alternate. List as many means of contact as possible (cell phone, home phone, work phone, and e-mail).

    You may also sign a 'DNR/DNI' if it is available in your state, but it's a flawed solution. It is a document that says that you do not want to be intubated (have a tube put down your throat) if you stop breathing, and you do not want your heart to be restarted by if it stops beating. However, even with a DNR/DNI form, unless it has something on it like, "I have terminal lung cancer," doctors will probably still opt to keep a patient alive at least until they can contact the family. I think the only thing a DNR/DNI form really does is give the family extra reassurance of your intent.

    In the end, there is no substitute for a responsible and easily reachable family that knows and respects your wishes.

    (Note that a DNR/DNI form is not a death contract. It can be temporarily or permanently revoked at will. A lot of people who would not want to be intubated or resuscitated in general might want it in a particular circumstance. For instance, a temporary intubation may be necessary for an emergency surgery that can actually extend give you more quality time.)