Thirty years ago, Dr. Lee Goldman wrote an article titled “Ten Commandments for Effective Consultation”. I’ve taken some liberties with his recommendations in the context of practice in an era...
Much of my clinical practice is in the intensive care unit. Currently, health care costs Americans 17.5% of the gross domestic product and ICU costs account for about 4% of health care. Therefore, I practice in a service area that accounts for nearly 1% of the gross domestic product of the United States. Therefore, it is incumbent on me to be a good steward of ICU resources.
It is pretty common for a patient to be admitted to the ICU and to be placed on life support: a mechanical ventilator, dialysis, vasopressor medications, etc. If the patient did not leave clear written advance directives, then it is up to the family to decide about the use of life support equipment. All to often, the family members’ instructions to me are “We want everything done, doc”. Having everything done means one thing when you are talking about a 30-year-old with severe asthma, but having everything done means a totally different thing when you are talking about a patient in a permanent coma from a large stroke or widely metastatic terminal cancer or severe multiple organ systems failure for which there is no reasonable chance of surviving. From the family members’ perspective, having everything done equates to being an advocate for the patient and is a measure of their love for the patient.
The way I approach this is to tell the family that we now have tremendous life support tools that we can use on patients but these life support measures were created to bridge patients through reversible illnesses so that the patient can return to a reasonably normal life. The problem with these life support measures is that sometimes, all they do is prolong the process of dying. We therefore have to decide for each patient when the life support is going to make them live longer or just make them die longer. I tell them that it is my job as the physician to tell the family when I think the patient has reached a point that the life support is merely prolonging their death. When put this way, most family members will opt to not escalate life support if all that life support will do is to prolong death. It gives the family another way of showing how much they care about their loved one by avoiding unnecessary suffering and pain.
I’m in a unique position. When I was a college student, before I became a doctor, my father was in the ICU at the Ohio State University medical center. He had advanced leukemia that was no longer responding to chemotherapy and was on a mechanical ventilator with sepsis and respiratory failure. The decision that my family and I was presented with was whether or not to start him on dialysis. I said no and 37 years later, I still think that was the right decision. All it would have done was make dying longer.
May 14, 2017