A 90 year-old man presents in an emergency department with abdominal pain and is found to have an abdominal mass. It is likely he has colonic cancer with impending perforation. He refuses colonoscopy, and he refuses surgery. “I am ready to die,” the man says, who is competent. The surgeons think they can help him. The man refuses again. The surgeons say that without surgery, this will be a painful way to die.
This scenario is being played out as I write in a nearby city. I was asked, as a former member of a hospital ethics committee, what I would do.
It’s difficult to say, without really talking to the patient and whatever family members are available. I don’t know whether the man has a living will or a health care power of attorney. If you don’t have either, I would do so at the earliest possible opportunity. Don’t think because you are in your 20s, this isn’t an issue. Accidents can leave people in permanent coma; Terri Schiavo, Nancy Cruzan, and Karen Ann Quinlan were all young, when a catastrophic event left each of them vegetative.
If the man is truly competent, he has the right to his decision. Patients have the right to refuse things that we physicians think they ought to have. This doesn’t hold for children, and more than one physician has given blood to a Jehovah’s Witness. But one is on shaky ground to treat a competent patient who has refused such treatment.
That doesn’t mean we have to take care of that patient for that particular illness. I had people refuse to take anti-convulsants for epilepsy. I said that I would provide a list of physicians to whom they could go, and they had 30 days to do so. I could not, in good conscience, have a patient whom I thought was a danger to himself and others be under my care, yet refuse my recommendations. But, I also would not, as some did, fire the patient and dump the case on the hospital medical director, which more than one time happened to me.
The “painful death” part disturbed me. Yes, peritonitis is painful. So is colonic surgery, with a colostomy likely, and the possibility of further surgery, poor healing, infection, or pulmonary complications, for major surgery on a 90 year-old will be complicated by definition.
We can control pain. We have palliative medicine physicians, and we have hospice. There is no reason for somebody to die in horrible pain. There are those who worry about addiction to morphine, which would be laughable in a dying patient, if the problem weren’t laughable and people really didn’t say that. But they do. We have a conflicting dichotomy in this country: hospitalized patients are asked constantly about how much pain they are having. Once you are an outpatient, then narcotics are bad things. Oh, it isn’t quite that simple; however, the truth is not all that distant, either. This dichotomy is grist for another mill.
There are others who worry that we will kill somebody by giving them so much morphine that they will stop breathing. Morphine depresses respiration, but if a patient dies by receiving too much morphine, isn’t that in fact what was going to happen anyway? What in the world are we so afraid of?
Death.
Not passing away, not going on to a “better place,” not “expiring”. Death. Dying. Ceasing to exist as a human being. I always used the term “death” in talking to families. I wasn’t always popular, but I was far more often respected by people I cared about than I was despised by those whom I did not respect.
Yes, I do worry about contracting certain conditions. I know medicine, and I know what can befall the human body. But I am also worried about being kept alive when I would not want to be. If I am vegetative, I wouldn’t be aware of it by definition, but it would be hell on my wife, and I would not want her to go through that.
I worry a great deal that I might end up in an ICU with a bunch of “keep him alive at all costs” folks working on me, long after it is obvious that the result will be poor and counter to my living will. I worry that somebody will point out a “miraculous cure after 20 years in coma,” when in fact the person was vegetative and happened to smile, which vegetative people do. I do not want my name associated with a court case, like the three women I mentioned above. Nor do I want to hear “you never really know what will happen,” when we do know with extremely high probability what will happen. The best thing I did in medicine was not curing people, for I did little of that. The best thing I did was allow people to die when it was time. I knew when it was time, not to “give up,” but to accept reality.
The next day, both hospice and palliative care people talked to the man and his family. He died soon afterwards. For me, he no longer exists. For others, he has gone to a better place, and they have memories of a long, happy life. For all of us, he is no longer suffering.
Boreal B[l]og 