Friday, July 27, 2007

End of Life Issue: Difficult to Let Go of a Sick Loved One

She had cardiac arrest at home. First responders resuscitated her and brought her to the hospital. The heart kept working, but the brain did not show any signs of recovery. The caring team including a neurologist agreed that the chance of the patient’s recovery was slim (note: nobody could say zero). The family contemplated withdrawing support, but one of the children felt that mom had tried to talk to him. After several weeks, the patient was taken to a long-term facility with a tube to help her breathe.

At times, we have a hard time letting go of a loved one even if we know that the chance of his or her recovery is minimal. This has important implications. One, we can put our loved ones through lot of pain because of our inability to decide. Two, this is an inefficient use of limited healthcare resources.

You can see this issue from two angles.

Patients’ angle:
- Whether a loved one lives on life support or dies without it- is a hard decision to make for most of us.
- I wonder if the health care system has failed to tell us that medicine is not perfect. There are many problems we can take care of, but there are lots more that we cannot do much about. A daily dose of news on medical advancements may be making us feel that death is just an option.

Physicians’ angle:
- Most of the physicians are not quite sure how to answer the question- will this treatment be futile? How do you define futile- less than 1 in 10,000 or less than 1 in one million chance of success? In the absence of a good definition, ‘futile’ can mean different things to different people.
- Most of the physicians are uncomfortable practicing paternalistic medicine. They feel uncomfortable saying, “I think you are too sick for this particular treatment and your chance of getting better is small (what does small mean, doc?).” They feel more comfortable explaining the overall scenario and letting the patient or loved ones make the decision.

Pro-Per™ points
- I think best end-of-life decisions are made when patient and/or family and physician are equal partners in the decision-making process.
- The loved ones find it easy to make these decisions on your behalf if you have expressed your wishes to them in clear terms.
- Should the doctors be paternalistic? I am ambivalent on that. As a physician, I am uncomfortable being paternalistic. On the other hand, if I am the patient, I would like my doctor to give me all the information with a dash of paternalism. I think that will make the decision-making easier for me.
- Various patient advocates- including physicians- should work on defining ‘futile’ in clearer terms. through action


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