A Good Death

Death is something that someone working in the medical field will encounter at some point in his/her career. It's always curious how different people handle death. Regardless, people tend to have a difficult time dealing with death, primarily with "letting go." The questions I've quickly come to ask myself when faced with a patient on death's doorstep include: Is this what the patient would've wanted? Are we prolonging suffering, or are our heroics actually giving the patient another chance at life? Is this a good death?

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My first patient died on my 2nd month of medicine. He came in with a massive stroke. Even if he were to survive, his quality of care would be very poor. Knowing this, the family decided that he should be DNR (do not resuscitate). They kept him on life-support long enough for his son to call their entire family and they flew in from all over to be with him as he died. My attending put the patient on palliative doses of morphine and withdrew all machines. He died some hours thereafter.

My second patient died on my 2nd month of surgery. I had met this patient from the outset. He came to us in clinic with terrible pain - pain that every doctor he had seen up to now had failed to take away. We warned him that the surgery we'd do could have a mortality rate of up to 50% due to his co-morbidities. He understood and wished to either have this pain taken away or die trying. He did survive the surgery but he suffered several complications that involved further surgeries. As my resident foretold one day, "He isn't getting worse but he's also not progressing. If he doesn't get out of here, he will die here." Later that day, he coded and CPR was done for almost an hour before a pulse was found. He was rushed to the SICU (surgical intensive care unit) where he was later found to be in PEA (pulseless electrical activity). The surgeon called his daughter who made the decision to withdraw care that night.

The following morning when the other JMS (junior med student) and I were pre-rounding, we read his death note. The other JMS gasped, "What?! She withdrew care? His family killed him!" I was furious because to me, his daughter saved him from what otherwise would've been a week of agony in a painful limbo between life and death.

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Why did we go into medicine? For many of us, it's because we wanted to help people, to treat people, to cure people. We want to make people better. Death is an endpoint. Death is THE endpoint, and one that some can't accept. We defer the decisions to treat or withdraw treatment to the patient and/or the patient's family (or other power of attorney). If they ask for heroics, we comply. If they ask to withdraw treatment, we comply.

But we could do better by our patients. I read an article, A good death is a right we must fight for, that spoke directly about this. In there the physician agrees that, when there's a real chance, we must do what we can to treat/fix/cure patients. But we also have a duty to ease pain and suffering. Many patients on death's doorstep are in a state of pain and suffering that only death can release them, precisely because we don't have the ability to bring them back towards life to the point where their quality of life would be tenable. We have technology to keep lungs breathing and hearts beating, but we don't have the technology to magically make diseases go away.

That all said, the decision to withdraw care is not an easy one and definitely not one to be taken lightly. There is indeed anguish and turmoil within those who must make such decisions. On the healthcare professional side, we may see the obvious answer as withdrawing treatment. But it's not that obvious to patients and their families, and we sometimes forget that. This video reminded me of what it must be like to be in the position to make that decision:

My Friend Jason. from Shot at The Dark on Vimeo.

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This lead to another interesting and poignant discussion that I came across:

When Doctors Face Death

How Doctors Die

Both of those articles talk about how physicians choose to die. In general, there are no heroics or struggles against death, but an appreciation for a life lived and a peace with death. They choose to die on their own terms in conditions they wish to die in. I'll wager that few people want to die in a hospital. More likely, people want to die at home with their family around them.

After seeing patient after patient suffer in the ICUs, at first a burning fire in defiance of death that later becomes a cool ember of surrender, I've quickly come to understand the profoundness in the words of those 2 articles. After hearing death rattles, after watching a patient on death's doorstep twitch and seize uncontrollably - unable to speak or communicate, after witnessing the pains of recovery from a heroic surgery to buy more time, I've to realize that that's not what I want.

What I think we all way is "a good death." What that is exactly may slightly differ for each of us, but at its core it's likely the same: to die on our own terms in the conditions we wish to die in. Perhaps only after seeing death are we able to truly appreciate life and realize that death itself isn't the worst thing, but rather the conditions surrounding it. We have no control over death. But we often do have control - to a large extent - over the conditions in which we die.