A Happy Ending

IMG_8299

“Well, Dr. Death here would like to just smother her with a pillow…”

The residents on service with me all shifted in their seats uncomfortably, glancing up to see how I was going to take the taunt.

What had I done?

I hadn’t punctured a lung during a central line placement. I hadn’t given the wrong medication. I most definitely hadn’t smothered her with a pillow.

My crime?

I asked most of my patients about their end of life wishes and defended those wishes vigorously. I worked hard to make sure dying patients didn’t suffer… Morphine nebulizer treatments for shortness of breath, benzodiazepines liberally for anxiety, heck I did whatever it took. And if you wanted to be “full code” well I could do chest compressions until rigor mortis set in if that was what you wanted.

The main thing, though, was that I just talked to people about dying.

It is a subject, frankly, that makes a lot of physicians uncomfortable. We are trained to try to save lives and as such we forget that death is as much a part of living as life itself.

So why am I even bringing this up? Because of the young woman with a terribly aggressive brain cancer who wants to kill herself. The Urban Doctor Mom wrote a great post yesterday about this, you can read it here: First Do No Harm..

Yesterday I thought I knew the answer.

Now, I am not sure.

I might actually choose to end my life if I were looking down the barrel of that gun. I am certain that someone else should not make that decision for me. It might not be the right decision for everyone but I sure think the freedom to choose is an important right.

There is a time to quit. Sometimes we forget that.

I have had patients with severe strokes in vegetative states get feeding tubes placed because no one had the balls to step up and tell the family that it is more humane to not do it. My family knows that under no circumstances should I be intubated (aside from surgery) or have a permanent feeding tube placed.

Watching your body stop working is terrifying. Heck, having to wear my “old lady glasses” to trim my kiddo’s finger nails was a huge emotional blow. I cannot even imagine what it would be like to lose bladder/bowel control, the ability to walk or feed myself, or to no longer have the ability to understand or form new memories.

That being said, I am not sure that as a physician I would be comfortable playing a role in ending someone’s life. I can give morphine to treat pain which might hasten death but I am treating the pain, not trying to kill. It is an important distinction.

Ultimately, we all just want a happy ending, even though what that means is as diverse as living.

Advertisements

39 thoughts on “A Happy Ending

  1. I admire her for knowing what she wants to do. I clearly hear her saying she doesn’t want to die. She wants to live, but existing under the burden her body has had placed d on it….is not living. God bless her and those she loves and who love her.

    Like

  2. You might enjoy reading, “Being Mortal: Medicine and What Matters in the End” by Atul Gawande. Just came out yesterday I think. I don’t know how I would handle willingly doing something to end my own life or playing a part in ending those of others. There are too many factors that make that choice complex.

    I do know that we have a lot of discussions about aggressive care and knowing when to quit despite having technology to “do everything”.

    Liked by 2 people

  3. I agree there is a time to quit; perseverance is important in many things, but so is knowing “when to fold ’em.” I am thankful my job does not require such weighty decisions, and also deeply thankful for those willing to help others abide by theirs … to face those questions and grapple with them, not just once but daily.

    Like

  4. This brings to mind an interesting autobiographical book, Imperfect Endings, by Zoe Fitzgerald Carter, whose ill mother planned her own death.

    Like you did, it’s so important to TELL people what you want, and get it in writing (I found my state’s form online and 2 people witnessed it and I made copies as per instructions), because one of the worst scenarios is family members arguing over what he or she “would want.”

    Like

  5. I thank God for the elderly doctor who pulled my father away from the young doctor. He explained that my grandmother was never going to heal, and that every treatment was simply addressing another failing system. They elected not to start kidney dialysis along with everything else. She passed quietly the next night.

    Liked by 2 people

  6. I’ve been with people I love at or near the end. There are no good endings. I think that the 29 year old who chose her exit is brave and right.

    Over two years ago I wrote a post about an article I’d read that says that doctors die differently. Because they know. http://fiftyfourandahalf.com/2012/03/04/hey-doc-what-would-you-do/

    I don’t want the extras when my number is up. Just the peace. And isn’t that what the cancer patient will get?

    Liked by 1 person

  7. Thank you for the mention. Sometimes I think we treat our pets more humanely than our fellow man. It’s a very difficult thing to think about. Our cat died a natural death at home last night, and while I realized it is not the same as a person, my husband and I had the discussion about euthanasia, should the time ever come. If we can talk about it so widely with our beloved pets, how is it that it’s such a taboo topic with our fellow man?

    Liked by 1 person

  8. When I am past the point of being able to make a positive contribution to society I no longer wish to live. I know others who feel differently. I think our wishes should be respected. I’m glad you’re out there doing that as a physician that has to be a tough place to be in. I know our laws are making it very hard for physicians and families to work together for end of life plans and it’s sad to see things go that way.

    Like

  9. Victo,
    You deliver this with compassion and understanding and a great deal of common sense. Of course it’s a difficult and sensitive issue and you can never please everyone all the time.
    Thank you.
    Best wishes
    john

    Like

  10. Conversations about end of life are (in my opinion) among the most important that we have as physicians. Whether that conversation comes as part of health maintenance or when the conversation HAS to happen, helping patients to think through what they want at the end of the road is such an incredible thing to be a part of. When my husband and I got married, the first thing we did was make sure the other understood our wishes. Romantic to be discussing feeding tube and end of life as newlyweds? No. Necessary, absolutely. As for how I feel from a provider perspective, I’m with you. I support whatever a person needs or wants at end of life, but I wonder about my own comfort with being the person writing the prescription.

    Liked by 1 person

      • I don’t see it dividing on sex lines as much as I do on life experience and family context. We actually had a training on talking about death and dying recently and I found that colleagues who were “non-traditional” medical students and who had close experience with issues of death were more comfortable than the younger medical students. For example, my husband lost his mother in high school, which frames our approach to the issue both as physicians and as a couple. Similarly, I grew up on a farm and our family has sustained a lot of loss in addition to that, so conversations about life, death and the process of dying are familiar and comfortable to me.

        Like

      • In my experience it has always been the male physicians who provide pushback. Not to say that there were not male physicians who did a great job, there were. But the women never just flat out refused or mocked the process. I am in a limited geographic area so I was curious what you had experienced. Thank you!

        Like

  11. My son was stabbed through the brain and left comatose with a GCS of 4 for several weeks with very high ICP, persistent subarrachnoid bleeding and a depressed fracture that left shards embedded in the frontal lobe. We had no hope of any kind of survival. I begged the doctors to allow him to die if that was his choice. Not to kill, but to permit. They couldn’t of course.

    My son survived and, against all the odds, regained all of himself and most of his body. We discussed my dilemma. He agreed I had done the right thing in trying to allow him to go. You cannot plan or legislate for those kind of situations.

    I have worked with a hospice charity and nursed my partner through terminal cancer. There is the possibility of choice there to a certain extent, yet none is permitted.

    Doctors are often blamed for this, but as your header says, beneath the white coat is a human heart.

    Sometimes all it needs is for death to be discussed and acknowledged.

    Like

  12. My Dad died a slow death over two years from Motor neurone disease, or ALS. I’d not change the time we clung to him, but I know he would. An animal would never be allowed to suffer as much as he did. If it were me, I am unsure what I’d do. I think it is brave to take your own life into your own hands.
    As for if something happened to me, my kids are non medical, but I have said over and over, if they hear the words, ‘catastrophic brain injury’ they must stop everything and understand, I am gone!

    Liked by 1 person

      • Yes you are right, but most of us think it will happen to that other fella up the road and not us, so some of us leave it too late.
        Thanks for reading mine. It was such a co incidence to read this post by you tonight. Made it very real.

        Liked by 1 person

  13. Reblogged this on Smorgasbord – Variety is the spice of life and commented:
    End of life decisions are very difficult and for doctors it must be so hard to stand by when someone is suffering and only have palliative care to offer. You can help however by making your wishes very clear in writing and noted on your medical records as well as with your close family members. You can also elect a person to make decisions for you should you be incapacitated. It is not talked about enough but like taxes death is inevitable but you can go on your own terms…

    Like

  14. Good post. I imagine it’s a tough issue for you because you’re pretty much called to talk with patients and respect their choices. I get the better deal in the equation because all I’m called to do is witness the process, provide some emotional comfort, and look after some basic needs.

    I am concerned that as a society we start moving more and more towards encouraging people to hasten the process for cost reasons, so as not to be a burden on their families, so as to meet cultural expectations. There’s no force required for this to happen, we’ll just slowly make it part of our consciousness, until people start to feel somewhat guilty about fighting for life.

    Like

    • Considering the cost of treatments is not necessarily a bad thing. Cost is more than monetary, however. Technology and medicine are such now that we can prolong the process of dying almost indefinitely.

      Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s