Response to a comment: November 21, 2008
Posted by keepbreathing in Uncategorized.trackback
I got an interesting response to my ethics post the other day. Here is the comment:
I got your comment and I am intrigued by it. I think you misunderstand me. You ask why it should be up to me who lives or dies. I am not saying that I, the respiratory therapist, should be in charge of who lives or dies. I am asking: just because we can keep somebody alive, should we? This is not as black and white as you think it is. When people say to us “do everything,” they don’t know exactly how much we can do. I’ll give you an example.
We have a patient at the moment who came in to us after he collapsed on a porch. He is indigent, with no family that will speak for him. He was formerly able to walk and talk, but after months and months in the ICU he has wasted away to a skeleton. He literally looks like a survivor of a concentration camp. He is incapable of moving his body. He is covered in bedsores as his skin has broken down. He is incapable of eating, talking, moving, or doing anything. Merely touching him causes searing pain to him; moving him, drawing blood, or doing anything else causes agony. His entire existence is pain. We can keep this man alive indefinitely; but it it humane to do so? Would you do this to your dog or your cat? I would not want to live like that and I am sure he would not either. His prognosis is grim: he has zero chance of surviving, yet we continue to treat him aggressively. Why? Why are we torturing him like this?
I am not advocating that we pull the plug on viable patients, I am advocating that we speak for the patients when care crosses the line from humane lifesaving efforts to inhumane prolonging of suffering. I am not saying that we need to establish a time frame; I am saying that we need to develop a better system of communicating with families and patients about how much we can do and how much they really want us to do. Do you want us to take your grandma, cram a breathing tube into her throat, pound on her chest to compress her heart, stick needles into her groin and extremities to give meds and draw blood? How far do you really want us to go? My own grandfather died a few weeks ago, but instead of demanding that they give him full CPR and keep his body alive on a ventilator in the ICU for weeks or even months at a time, we simply let him pass peacefully and with dignity.
You close by saying “You have a job to do. That job is to give everyone the best possible chance you can at survival. If you have reservations about who should get the best that you have to offer, you should find another career. People come to hospitals as portals of mercy.” We do give everybody the best chance at survival, but prolonging care at the end of life is not the same as giving somebody the best chance they have at survival. Care crosses a line from humane and lifesaving to futile and torturous quickly. If you asked everybody in medicine who was uncomfortable with doing absolutely everything to absolutely everybody to quit, then there would be very few people left in the hospitals. The real world is not as black and white as you seem to see it. The hospital in real life is not like the hospital on a soap opera: people don’t sit up after a round of CPR and say, “Wow! I feel better! I think I’ll go take a walk!” No, typically, they linger for a few days or weeks and then die anyway.
Finally, you say people come to hospitals as portals of mercy: that’s true. So why don’t we show them some? You’ve obviously never seen exactly what we can do to people to keep them alive. And there comes a time when we cross the line and are merely prolonging the suffering of another human being. The kindest thing you an do sometimes is to let somebody die.
All I am saying is: just because we can, does not mean we should.
Comments»
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1. Karla - November 21, 2008
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I’m not sure what the structure of your paper is supposed to be, but… content aside, I think structuring it as a response to a common misconception (i.e. that there are clear definitions of right and wrong; that the issue of “pulling the plug” is just a medical power trip of playing God, with little consideration for the patient’s well-being), deconstructing that through rational arguments and examples while at the same time proposing a new approach would be excellent. Kind of what you did in this response.
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2. AnnieC - November 21, 2008
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I loved your response above. Well put. Clear, concise, complete. I have been thinking about your paper and have some succinct ideas to send your way, but have been in the middle of mid-terms, so, have not had the time to answer your original question of “just because we can, does not mean we should” with any depth…but in my ponderings and reading your subscriber’s comments had this thought: “what if you thought you were the good guy, but were rather, the epitome of evil?” A version of this quesition was posted in a blog called “Decadaent Tranquility” and I have been having philosophical debates over it in my head…as I think, being a Good Samaritan Kidney Donor, a Health Care Professional, and a volunteer that I am the “goo guy.” However, in the name of goodness, I can say I have done things that I am certain are evil…like prolong the suffering of another human being. You have started a wonderful round-table discussion, and I’ve enjoyed every facet of it. Thanks!
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3. The Frozen RT - November 21, 2008
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I’ve seen both sides of this as I’m sure many of us have. I remember a pt in ICU who was thought to be a lost cause with all supportive measures maxed out. The Dr. talked to the family 2 or 3 times about withdrawing care but they refused. So we plugged along, day in day out, feeling like our efforts were futile. And wouldn’t you know it, after almost two months on the vent and then another couple in the ICU and on the ward and this patient left the hospital. We couldn’t believe it. We’d all thought we were ‘beating a dead horse’ for quite a while. Then I’ve seen others like the one described where the pt has all but died already. We’re simply circulating fluids and pumping gases. When people complain of health care workers playing God with pts life, it sort of bugs me. I don’t believe these decisions to withdraw care are made arbitrarily. There is often a lot of time, consultations, and personal mental effort put into deciding what is best for the pt, and yes, sometimes what is best for the pt is to let them go. Sometimes, playing God is keeping the pt alive beyond what should be. I think God is playing God sometimes when these people come to us in the first place and maybe we should let Him decide. Anyway, just because we can, does not mean we should.
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4. Rookie RT - November 22, 2008
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I think that society needs to evolve and develop a system to deal with end of life issues as a mandate for everyone. Perhaps along with social security or welfare or taxe. At a certain age, everyone has to decide and choose how they want to be cared for at the end… while they are still healthy… A formal agreement signed , notarized…whatever. Society does not face this issue in general, and it should. The best we do, is sell coffins now at Costco, and send in hospice once a choice has been made…if they are lucky…maybe…
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5. Mrs. Dreamer - November 26, 2008
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I am very impressed your logical and compassionate presentation on this topic. I remember in college working as a phlebotomist and having to stick some of these so very sick people. I’ll never forget the smell of death when I walked into these patients room. It made realize that when I’m at the end stage of a disease, I just want to please die at home.
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6. rogue medic - December 2, 2008
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You make some excellent points. Little in medicine is black or white.
When evaluating the outcomes of cardiac arrest resuscitations, the definition of survival is extremely important.
How many people want to be resuscitated to a drooling, incontinent, recipient of tube feeding, tube breathing, and tube medication to help move along the other tube delivered treatments?
While few would desire to have this abuse inflicted on themselves, some demand it for their loved ones.
What ever happened to the Golden Rule? Do unto others as you would have others do unto you.
The clarity, that many would like, is elusive in medicine.
The continued expenditure of vast fortunes, possibly to oppose God’s will, deprives society of limited resources, that might be used in many other ways. It is true that some of these ways would be wasteful.
But:
Medical research is how we develop the ability to learn what treatments work.
Preventive care, such as childhood vaccines, are not universally provided. Whatever your feelings on universal health care, the use of vaccines is different. Creation of a herd immunity helps to protect everyone, even the dangerous and irresponsible anti-vaccinationists.
More is available for the patients who might actually receive a benefit from treatment.
Caring for patients and prolonging life are not the same thing.
I have not seen Keep Breathing suggest that we not care for patients.
What kind of time frame wil you have? Will you establish a cut-off date like “Don’t give any care to anyone who looks like they will die in 48 hours.”
You have a job to do. That job is to give everyone the best possible chance you can at survival. If you have reservations about who should get the best that you have to offer, you should find another career. People come to hospitals as portals of mercy.