Recently, a frail, 90-year-old female patient of mine was admitted to the hospital with abdominal pain secondary to a large, probably malignant, mass obstructing the colon. An abdominal CT suggested possible metastasis to the adjoining organs. We discussed the options with her relatives: We could surgically open her abdomen and resect the mass-at the risk of grave post-op complications. Or, we could offer palliative care-a simple colostomy to relieve the obstruction and a referral to hospice. Her relatives insisted on surgery to remove the mass.
As expected, the surgeon found a large cancerous growth blocking the colon and a liver riddled with metastases. Given the patient's advanced age, the postoperative course was very stormy, with episodes of hypotension, atrial fibrillation, and respiratory failure. She died six days after admission. Her hospitalization cost $95,000.
Did we do the right thing for this patient?
But I know this patient isn't an isolated case. If you took a survey of elderly patients admitted to hospitals with a serious illness, how many do you think have provided advance directives? 70 percent? 50 percent? Not even close. In our hospital system, it's more like 25 percent-in spite of all the publicity surrounding cases like Terri Schiavo's.
As a physician, you might be tempted to throw up your hands. Yet we can't afford to do that. It's our duty to give our patients the best care possible, until the end-and that care can be gravely compromised when a person fails to make his last wishes known.
For example, has your plan for managing your patient's final illness ever been upset by family members who have no idea what their loved one would want? Overwhelmed by fear and indecision, they insist that you try everything, no matter how old the patient, how costly the treatment, or how incurable the disease. Or has your care ever been challenged by an adult child-often burdened by guilt-who demands, against all reason, that her dying mother be placed on life support? Or has treatment been delayed or complicated when attorneys got involved in family disputes over care?
I believe the time has come for some straight talk. Emotions aside, everyone should have a living will. Also, there's no point indulging in expensive last-ditch efforts to try to save a life that's beyond salvage. Withholding and withdrawing life support should be done whenever it's indicated and agreed to by two doctors caring for the patient as well as the patient's surrogate. Fidelity to the Hippocratic Oath does not mean preserving life at any cost.
These words sound severe, and I'm not suggesting you quote me to your patients. But you can show them the wisdom behind these words by practicing the true art of medicine. Conversations about death and dying are supremely difficult, but we must initiate them. When necessary, we must convince patients and their family members of the futility of further treatment. We can use our experience with the dying to help guide them through their fear and confusion.
And we can try to allay their concerns about unrelenting pain by introducing them to hospice, whose personnel will do all they can to make death gentle and easy.
And when there's nothing more you can do, no more will be necessary. You'll comfort them and they'll trust you-and that will be enough.