What we're supposed to do

Not half an hour ago, post-call after an exhausting night in our cardiac care unit, I stopped in at the residency program office to pick up my mail. At the top of the stack was an envelope with a familiar name in the return address--the name of a man I had taken care of while on a general medicine rotation a few weeks ago. Inside was my first thank-you note from a patient, written in a tender, newsy tone by an old man whose diagnosis I can't for the life of me remember.

It comes at a strange time. After my short time on the cardiac care service, I have become more dubious than ever before about the intentions of modern medicine, especially with respect to intensive and cardiac care. The past few weeks have been a blur of octogenarians admitted with new heart attacks who get every kind of resuscitation possible and at least one cardiac catheterization prior to settling in for the long dirt nap. Do they want it? Who cares? Our hospital lives and dies by its interventional services, and when a candidate comes in, we put on the hard sell.

A week ago, I shared my concerns with a friend of mine who's also a cardiology fellow. He was with me all the way: "We should be the gateways to the tests and procedures," he said, meaning that it should be up to us to determine who even gets offered resuscitation, cardiac catheterization, aortic balloon pumps, and the like. He insists our job is not to prolong life, but to prolong quality of life. It's a lovely thought, but the last few weeks (and several good studies) have demonstrated to me that at best, doctors are an over-optimistic crowd. At worst, we make up prognoses that justify our use of interventions--or maybe we offer interventions that justify our prognoses--and then we bitch about Medicare going broke.

As I've become angrier and angrier with our decision-making process in cardiology, I've become more and more distant from my patients and their families. Last night, I had to take a few deep breaths before going in to see the family of a 94-year old man, last week the recipient of a $30,000 pacemaker, who was coded after his heart stopped beating yesterday morning. The family was upset at his aggressive resuscitation and wanted to revise his code status to DNR/DNI. I wanted to shake them by their shoulders and yell, "Shouldn't you have thought about this before you spent someone's annual pay on that box? Do you think this shit is free? Are you even thinking at all?" I didn't know whether I was more angry with the family or with the cardiologist--and although I hid my feelings, I still felt them as I walked off the unit this morning with my coat in hand.

And then there it was, this mild, sweet, clear note of thanks from someone who was sick and got better.

With the volume of work and hours in intern year, it often feels that my patients occur as discrete points along the linear path of my training. As I read this note in my post-call delirium, I had a sudden vision of that path being pulled into a spiral, and the points falling into relief against a web, and the web being lit up by the times that we've actually gotten it right. We get things wrong a lot--especially over the last few weeks, it seems. But sometimes, we get things right. And even though that's what we're supposed to do, it somehow still matters.

More like this

Hurrah for the thank you note - always worth having and it is surprising how moving they are, no matter how many you receive.

And, "I hear you" on the remainder. A friend has a family member who has been persuaded to undergo very aggressive treatment for late stage lung cancer - despite very gentle suggestions from the medical staff that he is not physically robust enough to benefit from these interventions rather than some high quality palliative care.

I think everyone in medicine has had such thoughts, though you put it more eloquently than most. I would ask, though, that you step back from the individual cases, for a moment. They can be draining and can lead to a nihilistic mind set. But one of the roles of Medicine, in society, is to sustain hope. I submit that in order for that role to be fulfilled, it is necessary that we be overly aggressive at times. The trick is to find the right balance.

If we are not aggressive enough, we risk making ourselves, and society at large, lose a little bit of hope. That is not a trivial matter.

Of course, if we are too aggressive, it causes more problems than it fixes, which is worse, obviously.

All questions of ethics ultimately boil down to the same question: Who gets to make the decision? If you are perfectly clear and comfortable with the answer, experiences such as you describe might not be so troubling.

Thank you both for the thoughtful comments.

I agree in theory that it's a good thing to preserve hope. But what if we were to guide the sickest patients and their families toward hoping for something other than recovery, sooner rather than later? What if we were aggressive...in helping people be realistic about expectations? In controlling pain and maximizing the time realistically remaining to the sickest and the oldest patients? I think it's possible to do these things not as a last resort, once we've "run out of things to do," but as a different path of treatment that we pursue using the same risk-benefit calculations we use to make any medical decision.

Maybe I am again loopy with the post-call, but it seems within the boundaries of an experienced doctor to decide that someone should not have a certain procedure because it would be futile. Although if we had good advanced-directives conversations with patients, those decisions might not have to be made very often to begin with.

that is so sweet! Congrats, maybe you should frame it, like restaurants do with the first dollar they make :-)

Signout, bless you for caring. Even though you are so exhausted, you are right, an experienced doctor SHOULD be able to help his patient and/or their family decide that further procedures were futile. Right now, it doesn't happen. It's very hard on doctors, patients, and families. Perhaps hospitals are apprehensive about lawsuits, or perhaps doctors don't want to stop trying.

I am a volunteer lay minister who visits hospitalized patients. Over a two-year period, I visited several times with an elderly man. His wife had "taken care of him" to the point of managing his diabetes medications and diet. When she died, he had no idea how to care for himself. His daughters were 35 and 70 miles away, too far to check on him daily. He insisted he could care for himself at his home, but was frequently hospitalized because his blood glucose was out of control. The sixth hospitalization was different - he was in intensive care after a quadruple bypass operation. He never left the hospital. It took him 5 weeks in intensive care to die. It made no sense to perform this operation on him. He had poor quality of life before, and none at all for his last month. Was I angry at the family? Not as much as at the cardiologists who routinely, from the cath lab, make a consultation appointment with the cardiothoracic surgeons when blockages are too extensive for angioplasty. The tone of the doctor's explanation of the patient's options (as the patient lies on the gurney, recovering) seldom leads the patient or family to believe that doing nothing, allowing the patient to live their remaining time with dignity, without procedures, is also an alternative.

If the option of allowing the patient to live out their remaining minutes, hours, or days, is not suggested, families must ask, "What will happen if this procedure is not done? Are there alternative treatments? Should you contact hospice?" Most of them are so upset by the patient's illness that these questions aren't asked.

When you are finished with your residency, and practicing, you can be that doctor who stops doing procedures when it's futile. It won't be easy. You will need to discuss such issues with your patients when they are not in crisis. How wonderful the patient wrote to thank you! Please keep going - you will be a very good doctor! God bless you.

thank you! it's always heartwarming to read this sort of story. bless your heart and may you inspire many more medical students like me :)

By ditzydoctor (not verified) on 14 Apr 2007 #permalink

Eve, thanks for the overly kind words. I will certainly keep the note, even if I don't frame it. And ditzy (I wouldn't advertise that, by the way, ha ha)--thanks for the kind words, and keep working! It *is* worth it.

Lee, thanks so much for the story and the generous and thoughtful comments. It is much, much easier to hypothesize from my protected position as a resident about what kinds of things I'll offer patients when I'm practicing independently. Fortunately, there are some excellent role models out there for clinicians hoping to help their sickest patients avoid futile interventions and die with dignity. I hope I have the guts to be the kind of advocate these patients need.

Hi Signout - just found your blog. Very nicely written, and this post really struck a chord with me. I'm just a first year med student, but critical/intensive care is one potential pathway I'm considering. If I do go along that path, I hope to be one of those clinicians you mentioned who can use both hope and a realistic assessment of prognoses to help patients make the right decision on whether or not to have certain interventions. You gave words to my worries - I look forward to reading more.