What ist the greatest gift a physician can give to their patient? The right to die with dignity. Read on.
I once had a patient. An 87 year old man who lived in his own home. He mowed his own yard. He shopped for his own groceries. He cooked his own meals. He did his own laundry.
Like every functional 87 year I have ever seen in Happy's Hospital, he believed he would live forever. He did everything right in life. He never smoked. He carried a strong work ethic. He remained physically active, even taking in an occasional game of golf. He was the kind of man that drew people towards him. And he was loved. Oh was he loved. So many people. His room was packed. Man was it packed.
Then one day everything changed. It was his neighbor who found him. Bill always got his newspaper at the crack of dawn. But not today. What his neighbor found was a man without words. Barely able to breath. Unable to respond.
The field squad did what all great first responders do. They intubated him. The devastating nature of Bill's disease became apparent fairly quickly. Massive intracranial hemorrhage. Yesterday Bill could do everything. Today he could do nothing.
The neurosurgeon looked at the films. He looked at the patient. There was nothing he could do. Sure, he could offer the family clot evacuation and ventriculostomy. But for what end? Would it keep him alive? Perhaps. Perhaps not. Would Bill survive without surgery? Perhaps. Perhaps not.
Doing surgery may keep him from herniating. It may keep him alive. Or it may not. Nobody can say for sure what the outcome would be if he did something. Or if he did nothing. Nobody knows. What we have is a patient who lived their life well and finished strong. In the end, it's not about how much money you make, how many cars you own, how many vacation homes you bought. It's about people. It's about loving the people around you and trying your best to make the world a better place. It's about leaving your legacy of goodness for others to sunbath in.
The worst thing we could do for Bill was to offer him a therapy that turned a life worth living into a misery worth dying for.
I spent half an hour with Bill's family, explaining to them the grave nature of the situation. The surgeon never offered surgery. I never offered a countering opinion. Was it the right decision? Should the surgeon have offered an intervention that could have saved his life? Did the patient's family have a right to demand the option of surgery? Should the surgeon be willed into doing something he or she feels may or may not provide benefit? Even if the randomized controlled trials (none of which would be powered for 87 year olds) suggested a bias toward survival with surgery, should that data alone will a surgeon into emergency surgery if his medical opinion says otherwise? Is the medical judgment we as physicians bring to the table irrelevant in our practice?
Bill died peacefully with a full house of friends and family. I've been in this situation many times before. Many times before where patients die a miserable death filled with broken ribs, and broken hearts. What struck me with Bill was how peaceful he was. Mixed amongst the beeping telemetry monitors, the beeping IV poles and the beeping ventilators was just peaceful Bill listening to the orchestra of sounds around him.
We as physicians are very capable of taking a peaceful and natural process and turning it into a horrible, painful and emotional roller coaster that will ultimately be filled with nothing but disappointment, heart ache and bankruptcy. We as physicians are very good at avoiding reality ourselves. It's much easier to look a patient in the eye, offer them everything and say, "It's your decision. What do you want to do?"
We as physicians are very good at avoiding end of life ethical issues. It's easier just to do surgery because we're doing something. And, well, it's just quicker and easier. It's easier to give chemo because we're doing something. And, well, it's just quicker and easier. It's easier to intubate grandma because we're doing something. And, well, it's just quicker and easier.
By doing something, we as physicians are robbing the greatest gift we can give a patient. And that's the right to die with dignity. I will not step down from my belief of letting our elderly die peacefully, when I and everyone around me know the horrors that await them should we decide to offer them everything, when we all know that by offering them everything, we are in fact giving them nothing.
Death is not miserable. A miserable death is.
