Procedure Meat: How Procedural Lust Imperils Patients

I'll start with a macabre anecdote of crassness, to get everyone's attention.  It is apropos because procedural lust has crass and macabre consequences.

It was about 17 years ago, while I was in training, that an attending accepted a moribund woman from a faraway place in the hinterlands.  She had multiple hepatitides and uncontrolled bleeding from esophageal varices.  A collective groan among the housestaff met notification of the incoming transfer which would keep everybody up all night with the inevitable death forestalled only briefly, and in a streak of his usual candor, the attending admitted that he accepted her not because he thought there was anything that could be done to help or save her, but because she would serve as good "procedure meat for the interns."  And the interns were like:

There are a lot of problems with that entire episode as I reflect upon it, and I won't dissect them all here.  I've been thinking about procedure meat because I so often see physicians feasting on it, to the peril of the patients.  Ideally, each and every procedure that is done ought to be done because it is in the patient's best interest to have it done.  All too often, ulterior motives and unstated goals creep into decision frameworks and lead to unnecessary procedures and therapeutic misadventures.  To combat this problem, we need to start nudging physicians to consider and patients to ask directly, "Is this procedure the best thing for me?  Are there alternatives?  Do the expected benefits outweigh the costs and risks?  Where will I be in six days, six weeks, six months, and six years as a result of the proposed procedure?  Where will I be at those times without it?"

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.)