Dr Gawande, in his New Yorker piece on hospice, relates the story of a young woman with terminal cancer who progresses down the pathway to intubation and the ICU at the end of her life. He writes:
This is a modern tragedy, replayed millions of times over. When there is no way of knowing exactly how long our skeins will run—and when we imagine ourselves to have much more time than we do—our every impulse is to fight, to die with chemo in our veins or a tube in our throats or fresh sutures in our flesh. The fact that we may be shortening or worsening the time we have left hardly seems to register. We imagine that we can wait until the doctors tell us that there is nothing more they can do. But rarely is there nothing more that doctors can do. They can give toxic drugs of unknown efficacy, operate to try to remove part of the tumor, put in a feeding tube if a person can’t eat: there’s always something. We want these choices. We don’t want anyone—certainly not bureaucrats or the marketplace—to limit them. But that doesn’t mean we are eager to make the choices ourselves. Instead, most often, we make no choice at all. We fall back on the default, and the default is: Do Something.
If this is true in medicine in general it is doubly true in the ER. There are a number of reasons for this -- the position of the ER to see people at the point of transition into acute dying, the fact that we don't know our patients, the fact that we often have to make treatment decisions based on incomplete information, the fear of litigation, and the fact that we are kind of a bunch of adrenaline junkies.
The other day I saw an elderly man with a very serious illness. He had a slow GI bleed and got his hematocrit down to 15. Yes, that's not a typo: he was a functional anaerobe by the time I saw him. He was a vasculopath, and eventually he tipped over into multi-organ system failure. It wasn't until he infarcted his small intestine that the pain brought him in to see me.
It was pretty obvious he was on his last day -- his lactate was 16, and when your lactate exceeds your hematocrit, well, that is a grim sign indeed. He also was having an MI, and in renal failure and in early CHF. His pH was 6.8, which is the lowest I can recall ever seeing. I got his pain controlled and instituted the standard resuscitative measures -- fluids, blood, antibiotics, etc. Once his pain was managed he was actually lucid and in good spirits and able to chat with his family while the nurses and respiratory therapists hovered over him.
Predictably, the massive fluid bolus began to back up into the lungs and he became progressively more short of breath. The family and nurses and RTs all became progressively more distressed by his labored breathing. At one point I faced a delegation of three nurses and two RTs imploring me to intubate. Quite frankly, that was my reflex as well. Intubation for ventilatory support is pretty standard care at this point, and I was on the verge of telling them to get things set up. But a strange reluctance seized me. With "Letting Go" fresh in my mind I said I would go talk to the patient and family instead.
I laid things on the table for them. I looked the patient in the eye and told him that this was it, that "You are going to die from this, and probably today." This is an exceedingly hard thing to say to someone, by the way. I asked him how he wanted to spend his final hours -- sedated and intubated (but comfortable), or awake and able to spend time with his loved ones, with pain medicines as needed. This was, as you might imagine, a tough conversation and one I might well have shied away from in the past. Frankly, it would have been way easier to simply put him down, intubate him, and ship him up to the ICU for the intensivists to deal with. The wife was not quite ready to let go, and I had to make it clear that this decision point was not going to change the outcome -- it was not giving up, only recognizing the inevitable and choosing the manner in which it would come to pass.
He chose to be awake and spend the time he had with the people he loved. We slammed on the brakes of the medical machinery and started a morphine drip. He still went to the ICU, but with "comfort care" goals and a consult to the palliative care team.
I'm really happy we did what we did -- or more importantly, what we did not do. It was not the path of least resistance, not at all. Some of the nurses had a tough time with it emotionally, but I think it was generally recognized that this was the best possible outcome. This was an easier case because it was so clearly not survivable, but the many many cases with more uncertainty are in a different category, where the default to "Do Something" leads to a lot of human misery.
And I am not sure what to do about that.