Andrew Coates: Facing Death And Hope
A man in his 90s became very ill and was brought to the hospital by ambulance. The emergency room physician called and asked me to admit the patient to the intensive care unit. I was upstairs in the hospital.
I briefly studied the electronic record before heading downstairs. I learned that the man suffered from dementia, advanced to the point that his primary care physician was unable to have any meaningful dialogue with him for several years. I also saw data to convince me that this man was critically ill.
In the emergency room the physician reviewed with me the things that he and the nurses had initiated but added that in the bigger picture that he thought the patient was dying. He mentioned that he had asked about “do not resuscitate status” but that the patient’s wife didn’t have an answer. She "wanted everything done.” He had explained the need for intensive care and called me.
As I evaluated the patient I found a man poorly responsive and generally very ill. He had cachexia, which means wasted muscles and body mass, in other words he was beginning to look like a skeleton. His mental status and vital signs suggested that critical care measures already initiated were appropriate. Given the patients advanced age and profound frailty, the emergency room physician was probably right, I thought, this patient appeared to be dying.
“I am so sorry to say this,” I told the patient’s wife. "When he couldn’t eat over the last few days, it was a sign that he was starting the very last chapter of his life.” As gently as I could, that death might be imminent, no matter what treatment we offered.
There was a pause.
“I like that other doctor better.”
The patient’s wife was referring to the emergency room doctor who had assured her that we would do “everything.” She was not ready to face her husband’s end, nor to hear the event spoken about.
I sat with her for a quiet moment. After years of supporting him in their own home, she would now be relegated to his bedside, watching the hospital staff perform his care. I listened to her recount the details of their usual day and wondered how I could best help her. Compared with their usual routine, the strangeness and stress of the experience seemed enormous.
As a hospital medicine physician and also a hospice and palliative medicine physician, I have experienced many moments like these. These silences illuminate our social acquaintance with — or perhaps our everyday distance from — the experience of illness and death and how our system fails its patients.
Three weeks ago we had a death in our own family. My father-in-law had suffered three cancers, the last one incurable, and he was fading away over his last months. In the end, when he collapsed, the ambulance was called and he too went to the intensive care unit for the last day of his life. My colleagues asked if his death was expected. It was, I suppose, but when it came, the social dislocation and stress were profound.
When it comes to serious illness, the infirmities that come with age, and the process of dying, our health system is unnecessarily inhumane. Over the recent decade, of those who die in the United States, the percentage who receive care in the ICU during the last year of life has risen from about 1 of every 5 to nearly 1 of every 3.
Facing a loved one’s death is overwhelming. Since the chances are very good that all of us will face death, it seems obvious we should be devoting our resources to building a system based upon caring for patients with the kind of dignity they deserve.
But to do so would take a profound change in direction for the whole nation. Instead we have health policy dominated by the financial interests of so many corporations, insurance companies, the pharmaceutical industry, profits from devices and all kinds of schemes to extract resources from caregiving.
The contradiction remains that with so many capable caregivers, such advanced medical science and technology and so much of our national budget at the ready, we could do so much better. And in that contradiction lies the hope.
Dr. Andrew Coates practices internal medicine in upstate New York. He is President of Physicians for a National Health Program.
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