As a family doctor working in a small community hospital, I know that sometimes my patients will die. One of my most difficult tasks is deciding when to change strategies, when to shift my focus from keeping the clot, or fluid, or bacteria, or malignancy at bay, to palliating that patient at his or her life’s end. Tom Koch, in his opinion piece, “End of life, year after year after year,” 1 suggests that we physicians are too often premature in our judgment, depriving our patients of lives they might have had if only we had tried a little harder.
The anecdotal argument that Koch employs to make his point is wearyingly weak. He tells the tale of pseudonymic Fred, who outlives his doctors’ prognoses by a good three years, and pauperizes himself well before his time on earth comes to an end, believing that time was short. If only his physicians had been more circumspect! (Or smarter, I suppose.) I have no doubt the story is true — mainly because those of us in clinical practice have all heard stories about Freds. The grandmother who smoked two packs a day until she was 95 and was never sick a day in her life. The friend who declined chemo- and radio-therapy and had his cancer go into remission. But there is a reason why these stories carry so much emotional currency for patients and their families — they are the exceptions, not the rules.
True, it is very difficult to predict when a patient is going to die and I have been wrong many times. However, if you were to plot my best guesses against the sad realities, you would find a rough correlation. Outliers there will be, but the trend would be recognizable. Most physicians appreciate that they are making educated estimates, and the oncology consultation notes that I receive are couched in appropriate qualifiers: “on average ...,” “research suggests ...,” “might hope for ...,” In some cases, I know that patients stopped listening after the number hit them, too numb.
What Koch does not address is the harm done to patients (and their families) by pressing on with aggressive medical management in the face of very steep odds against good recovery: intravenous restarts; swallowing contrast; blood cultures at 3 am; copious diarrhea from antibiotics; relinquishing control of one’s breath to bi-level positive airway pressure apparatus; Nalox-one-induced withdrawal because of respiratory depression; the consequences of fluid resuscitation: incontinence, catheterization, or endless assisted trips to the bathroom; the bruising of low-molecular weight heparin; the noise and lights of a medicine unit, or ribs crunching under the weight of cardiopulmonary resuscitation. In acute treatment, all of these things are accepted as inconveniences, the lesser of evils, means to an end. In the treatment of a patient who is unlikely to survive, they can be cruel.
Koch implies that we (physicians, that is) are such poor predictors of mortality that we should abandon the task. In many cases, I would love nothing more than to abdicate such responsibility. However, the people asking me to make such determinations are not hospital administrators anxious to clear beds, but the patients, their spouses and their children. It is a weighty task, because crucial decisions for the patient hinge on my advice: Should I undergo some suffering for the hope of eventual good? Should my family’s life be disrupted to be at my bedside? Are there things left undone that need doing? I feel that weight. I feel that it is also my job — not inerrantly to predict, but to guide and to advise.
I talk about odds — I never rule out surprise, and will be the first to celebrate when my patients surprise me. Still, I’ve never been much of a gambler — the logic of a scientific medical education drilled that out of me. By definition, gambling snubs rationality, hoping for the big payout when the more likely outcome is incremental losses. Those of us who care for patients at the end of life know what those losses look like. And those of us who care about our patients will not forget those losses when they look to us for help with those decisions on which their lives — and deaths — will turn.
Footnotes
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Previously published at www.cmaj.ca
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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