Your Last Words for a Few More Breaths: Unspoken Trade-offs in End-of-Life Care

A man with widely metastatic cancer is admitted to the hospital for shortness of breath, deteriorates in spite of broad spectrum care, and is transferred to the ICU.  The patient is documented to be "full code" and, while the prospect of "coding" him is unsettling for his providers, they struggle to articulate exactly why.  (Correct intuitions are often difficult to dissect and describe.)  Often the discussion (amongst themselves or with the family) centers on the direct, observable, physical aspects of suffering that must be borne by the patient during the resuscitation process and/or the transition to life support.  "Breaking of ribs" and the like.

But years of quiet and thoughtful reflection identifies some second order and often unspoken nuances of the transition to life support that are perhaps more important than the first order physical aspects.  When the man dying of cancer deteriorates to the point that his oxygen saturation cannot be supported without life support or his respiratory distress is too severe, and I position myself behind that bed, propofol and an 8.0 (endotracheal tube) in hands, I know the oft unspoken truth - that this is the last time that this man will be indubitably conscious and coherent or will speak to anyone, most notably his family.  Insomuch as life consists of an interaction with one's environment, with a central focus on social interactions, the patient dies the moment I induce with propofol and insert that tube between the vocal cords.  He has traded his last words for a few more breaths.  (He has also traded away his ability to enjoy food or drink.)

Reconsidering the Premises of Care: The Patient Perspective and the Relief of Minimalist Medicine

This post is about some half-baked ideas that result from inferences I have made after noticing some patterns in my dealings with patients, inspired by one such interaction today.

Every now and again I have noted that some patients seem pleased by something I say, some perspective I present, and their pleasure I infer from their asking for my name and contact information so that they may pass it on to their other treating physicians.  This is somewhat unusual since I make clear that I am a dedicated inpatient doctor who only briefly contributes to their care in the most acute of settings.  And I have noticed that it is most likely to happen when I offer to them a perspective that gives permission, as it were, to pursue a less aggressive course of care even in patients who are not really at the very end of their lives.

Today, as is often the case, I suggested that a patient may wish to simplify his medication regimen, eliminating medications that, while constituents of an "optimal" regimen, are adding very marginally to his longevity while posing some very real burdens.  This patient has some longstanding chronic conditions but his medical regimen increased dramatically in complexity after a recent cardiac illness, such that he now takes two antiplatelet agents, an anticoagulant, and several medications for blood pressure and heart failure in addition to several medications he has been taking for years.  Since his most recent hospitalization six weeks ago, he has felt terrible.  This is either related to the setback he had with his recent cardiac event, or from the post-hospitalization syndrome detailed in the post about Death by 1000 Needlesticks, or, and this is not to be taken lightly, the cumulative side effects of his now complex medication regimen.  Indeed, the current hospitalization has occurred as a result of bleeding complications triggered by medications from his last hospitalization.