The opiate post segues into something I’ve been grappling with periodically - the ethics of medical intervention when the outcome for the patient might be terrible, or even futile. Cases such as patients with massive heart attacks, who then end up with severe brain injury. Or the trauma victim who lives, but in a vegetative state. The one pound neonate born at the edges of viability, who survives as a severely disabled child. I do not know the answers, and I don’t know how we make such a decision about outcome when most of these scenarios present as an emergency with no time for considered thought. It’s troubling me more of late though. I have a colleague who ran into an affected family member of a patient for whom she’d cared, during such an event some years earlier. The family member recognized her, and asked if she was proud of herself for what she’d done. The patient involved was only saved through advances in modern medicine - not so long ago, such a patient would have died. At the time, this family wanted nothing more than for their relative to survive. Now, they carry the burden of caring for a patient with no meaningful quality of life. Their marriage has broken down and future dreams shattered. Although I ached for my colleague, having such anger directed at her, I could understand the place from whence it came. The problem is, there will always be that success story, the patient brought back successfully from a devastating injury, the neonate born at 24 weeks who is now a happy, functioning, bright child. There is no pause between the presentation and the decision to treat in which to make a choice, no crystal ball to guide us. The principle of non-maleficence is very hard to apply in those precious moments of a resuscitation. We have statistics, as to who might fare poorly and who might do well, but how do statistics help if you are the family member burdened with making the decision to discontinue treatment, or in the case of a very premature neonate, to never start treatment? How do we as doctors guide them? As we sit by the patient who looks to have a dire outcome, how do we advocate for that person and family, when we can never be sure which statistic they will be? We can quote the statistics, but how does a parent or a relative choose to not treat, how does one choose to let another person die, when the numbers are not black and white? What would you do if it was your family member, your neonate? Are we doing the right thing, saving such patients, just because we can?
Jess
As a doctor, you care for the entire population even if it is one patient at a time. Everyone is connected, given enough degrees. Your counseling should be based on the realistic likelihood of success as well as the fortitude of those who will deal most directly with the consequences.
ReplyDeleteStatistics is probably the most understood topic out there. Trying to communicate "the odds" on a patient's condition or the value of a procedure can be very challenging, even to people who are smart. It helps to say the same thing in many different ways. The patient has a 20% chance to return to normal life | The patient has a 1 in 5 chance to return to normal life | For every 5 people that undergo this treatment, one person has a positive result | etc. Some people need visuals to understand the odds - pie charts can succeed in communicating where words (and numbers) do not.
In the end, we all have to say goodbye sometime, and sometimes it's up to you to help people make that call. How would a negative outcome affect this family? How would a positive outcome affect them? These are questions you must answer yourself in order to give meaningful guidance.
Some people find a way out of hard problems like this with an ideological stance like "it is always better to preserve human life" but that has not been shown to be true for society at large. Keeping the permanently suffering or severely disabled artificially alive diverts finite resources away from healthy people who are suffering under far more preventable circumstances, and this must be weighed.
Thanks for posting on this complex issue. On the same day as your post I came across this piece in the NYTimes well column/blog, They Call Me 'Dr. Kevorkian' by Jessica Nutik Zitter http://well.blogs.nytimes.com/2013/11/14/they-call-me-dr-kevorkian/?ref=health that you might find relatedly interesting, on end of life issues, palliative care, and the ICU
ReplyDeleteI think this article "How doctors die" is one we should take to heart. If it were my/your/our family member, we'd probably make the decision quickly (I know I did when my grandmother had a SAH from an aneurysm), and it would be for not pursuing futile care. And yet it is so difficult to communicate that to patients and their families. I'd like to see medicine investigate how to do a better job communicating what we know is the right thing to do for ourselves. http://www.zocalopublicsquare.org/2011/11/30/how-doctors-die/ideas/nexus/
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