Futile treatment is on the rise

This is perhaps my biggest single frustration as an ER doc. Family members bring their loved one that looks like a gasping corpse. Death is right in front of them and they can’t acknowledge it, nor apparently can their oncologist who gave them chemo last week. When you have metastatic cancer, are encephalopathic, have skin jaundiced as a pumpkin, a tongue that looks like a prune, and are breathing like a fish it is time to peacefully let your loved one die. Yet family members routinely want me to resuscitate dying flesh and flog their body with tubes and lines so they can be tortured another week or two longer. NO ONE WANTS THEIR LIFE TO END THIS WAY, but family members willingly do this to their loved ones. I try to kindly talk about the option of DNR and hospice care and I often get an incredulous, angry response. I blame the oncologist, the PCP, the family, and also the patient for not having an advanced directive spelling it out for panicked family members.

You know guys MOST of the times the “lazy” oncologist has addressed this issue with the family. The family has chosen not to pursue hospice. You can lead a horse to water but you can’t make them drink. Believe it or not it can be frustrating for the oncologist too. Shall I go step by step about what irritates me about ER docs?

Dr. Onc,

No offense intended to you personally. I don’t want to get involved with a tit-for-tat list of irritants. It is a very special person that goes into Onc Many people on this blog take generalizations too literally and personally which limits good discussion.

But don’t you think it is disingenious to still be giving chemo if you really do think it is futile and that “they should be led to the water”? Is it the social and legal climate that makes us do this? I can be accused of the same thing when I intubate someone that I know is a futile move but have to do it because:

1) The family says “do everything”. When I ask them if this is what the patient would have wanted they pause briefly (because they know the answer is NO), but then say YES, YES anyway.

2) The outcome of course is going to be bad and you are more likely to get sued if you are perceived as “giving up” or “not doing enough”

There is a financial incentive for the oncologist to offer hope and chemo. In my limited experience (5 years as an internist), the oncologists usually do not give chemo to people with a poor performance status. What happens much more frequently is that the patients walk into the transfusion center for their chemo looking okay, and then the poison makes them nauseous and dehydrated for the next week. Then they show up in the ER and the admitting Internist and ER doc grouse about how aggressive and greedy the oncologist is.

Neither the internist nor the ER doc would have felt comfortable a week before telling the ambulatory patient they should go home and die.

Regarding DNRs: Even if you have one, it’s no guarantee that it will stop medical personnel from taking “heroic measures”. Following a series of strokes, my uncle was placed in a nursing home. My mother was his POA and talked with him about DNRs; he requested such an order, and it was placed in his chart.

Nevertheless, he had another major stroke while at the nursing home and medical staff intervened. When he stabilized, a nurse told my mother that she was so pleased because they thought they’d lost him.

My uncle did not recover fully. He suffered brain damage and remained bedridden at the nursing home until his death two years later.

Two morals here, I suppose. One, I guess you need to make very clear to anyone who might treat yourself or a relative that there IS a DNR on record. Two, not everybody in this world is looking for a lawsuit. My family, while not pleased that the DNR was ignored, understood that the people who worked on my uncle were probably dedicated cargivers who must find it nearly as difficult as the families to let go sometimes.