A doctor reckons with what's owed to a patient's family members.
We gathered as a medical team in front of my patient's room early one Saturday. She was one of the sickest patients in the intensive care unit. Her lungs were destroyed by cancer and a rare reaction to her chemotherapy, and her condition worsened each day, despite aggressive interventions. It was clear that there was nothing more that we could do. Except to keep her alive until Monday.
Struggling to come to terms with this reality, her family had begged us to continue our interventions through the weekend. So we would keep her intubated, deeply sedated and, we hoped, pain-free, performing the rituals of intensive care until the family was ready to say goodbye.
There is a largely unacknowledged moment in critical care when doctors and nurses shift from caring for the patients in front of us to caring for their loved ones. Often these two aims are not inconsistent: Even when family members like these are not ready to stop life-prolonging interventions or ask for a treatment that is unlikely to work, they are speaking on behalf of the patient. But increasingly I wonder if it is possible to go too far to accommodate family. When a patient is at the end of life, what is our responsibility to those who will be left behind? (continues)
We gathered as a medical team in front of my patient's room early one Saturday. She was one of the sickest patients in the intensive care unit. Her lungs were destroyed by cancer and a rare reaction to her chemotherapy, and her condition worsened each day, despite aggressive interventions. It was clear that there was nothing more that we could do. Except to keep her alive until Monday.
Struggling to come to terms with this reality, her family had begged us to continue our interventions through the weekend. So we would keep her intubated, deeply sedated and, we hoped, pain-free, performing the rituals of intensive care until the family was ready to say goodbye.
There is a largely unacknowledged moment in critical care when doctors and nurses shift from caring for the patients in front of us to caring for their loved ones. Often these two aims are not inconsistent: Even when family members like these are not ready to stop life-prolonging interventions or ask for a treatment that is unlikely to work, they are speaking on behalf of the patient. But increasingly I wonder if it is possible to go too far to accommodate family. When a patient is at the end of life, what is our responsibility to those who will be left behind? (continues)
How to deal with dying patients is always a tough call for medical practitioners. Part of the problem is that no matter what the will of the patient (DNR for example) a consensus among family members often does not exist and those who have been further removed from the scene may enter into the picture late and not be as far along as other family members in the grief process and in accepting the inevitable. Also, it is never just about what family members think. Often, what they feel, where they are emotionally, their spiritual condition, and their psychological condition/diagnosis may enter into the picture. Finally, medical personnel responding to a code may just react and let their training kick in without taking time to review the patient chart and whether or not they have expressed certain wishes about how they would want this incident to be handled. My father was put on life support in the middle of the night against his express wishes leaving my family to make a decision to pull the plug the next morning on my already brain-dead father. When I realized that his heart attack may have been brought on by an ill-conceived medical procedure I had to wonder if the life support wasn't done to distract us from the possible medical error that may have been committed. We had no stomach for a malpractice lawsuit at that point, but I am sure that some hospital staff members are always fearful of and defending against such an outcome.
ReplyDeleteThat must have been excruciating, Gary, for you and your family. I suspect you may be right about the hidden motivation. There ought to be a better way of insulating health providers from such legal fears (short of actually losing the concept of medical malpractice, which is of course as real as medical error).
DeleteThis is interesting! Honesty, I do not know if there is one clear answer to this issue. Everyone's experience and situation is so vastly different, so it would be difficult to pin point the proper response. I have been on the family side of this situation, but I will say... I think above all, patient comfortability should be top priority.
ReplyDeleteGosh this is a tricky situation for healthcare professionals. The decision making here is clearly influenced by the heavy emotionality of losing a loved one. I agree with Julianna that ultimately the goal should be the patient's comfort in their last moments. If a family wanted to prolong their loved one's death despite the fact that doing so would likely result in great discomfort to the patient, perhaps the ethical thing to do would be to ignore their wishes. But consider that the family desired to prolong the death until another loved one managed to fly into town the next day. Despite their discomfort, I would imagine that the patient would want to persist until said loved one was there to say goodbye.
ReplyDeleteThis is a huge bioethical issue. Do you end up caring more for the family or patient themselves? My opinion would have to be on the side of the patient, though this could vary from case to case. Ideally, patients that still have some sort of autonomy would choose. It's a dreading situation. Personally this situation in particular is one of the reasons I prefer to eventually go into primary care. As a primary care physician, I would have to stomach this decisions constantly.
ReplyDeleteI definitely agree Kirolos, I think the patient should always come first. Of course there has to be a balance between all of the doctors decisions, but definitely the patient comes first. I think that we would be readily trained to deal with the family, and I really hope so.
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