The price for improvement sometimes outweighs the benefits

After getting off a 15 hour call day, all I want to do is write.

These past 2 weeks death has been on my mind a lot, more than it ever has been. I have always known that physicians counsel patients and families on dying, but actually being the one to do it is entirely different.

How do you tell someone that their best medical option, the best thing you can offer them, is to die? As medical professionals, it is hard to say for a number of reasons.

One, our goal is to keep patients alive, and admitting defeat and giving up can be difficult. Two, on a humane level, how do you go about conveying that message to a living breathing human being? You feel like you are destroying their hope, taking away what little fight they have left in them. It’s a highly unnatural and difficult conversation to have and yet so important and necessary in end of life care. It is really a privilege for physicians to be able to partake in what is arguably one of the most important discussions in a patient’s life.

I have been thinking about my grandmother who passed away last June. She had been diagnosed with congestive heart failure back in 2011, and steadily declined throughout 2012. After multiple trips to the ER and spending weeks inpatient, she and my extended family decided that she did not want to live her last few months in a hospital, eating sodium restricted hospital food, never getting enough sleep, and constantly surrounded by strangers. She went home and lived the way she wanted to until she died in her own bed a few months later, surrounded by family. We had cut down on her medications substantially by then, and all she received at the end was morphine to help with the pain. My mom has expressed to me multiple times since then that she wants to be DNR/DNI (do not resuscitate, do not intubate), meaning that if she were to decline, she does not want a breathing tube or to be put on a ventilator, and she does not want CPR.

It’s hard for me personally because I am pro-medicine, pro-treatment. I want to try everything I possibly have in my arsenal for my patients because I want them to get better. Why stop an intervention if there’s a chance it can help? But what I’ve come to learn is that sometimes the price to pay to get a tiny bit of improvement far outweighs the benefits.

At the end of the day, patients may decide to choose quality of life for a shorter period of time over trying to improve their medical prognoses. And that is an equally respectable and admirable decision. I know that as a future physician, what I say during these goals of care discussions can really sway a patient’s decision about further interventions. I just hope that I can compassionately but also rationally help patients navigate through the options until they decide on one that’s the best path for them. Someone did it once for my grandmother, and I know that it changed her life for the better.

Joyce Ho is a medical student who blogs at Tea with MD.  She can be reached on Twitter @TeawithMD.

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  • Ron Smith

    Very good post, Joyce. What I would be interested in too, is how you particularly view life as a whole, not just life that you perceive in your hands as a practitioner. A practice view that views a patient segmentally from the first time that you see them until you sign a death certificate, however compassionate, loving, and caring, seems sterile to me.

    Is there a spiritual aspect to your experience with your grandmother?

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com


    Joyce, great post. I enjoyed reading it. Good luck to you in your studies.

  • L Jones

    I must present to you, an opposing view – the one that indicates that sometimes too many “physicians” take this upon themselves to advise a patient that they have (place the number of months/years here) left to live.
    As someone living with an aggressive breast cancer, I am blessed to have joined a group of 350 women with this rare cancer and have been sickened by the amount of women who are told, upon reaching Stage IV, that they have at most, 2 years left to live.
    We actively encourage these women to immediately fire their current oncologist and get a better one.
    In a lot of these cases, the supposed “2 years” gets passed ages ago and the person is still around some ten years later.
    While I understand the message that you wish to present, we have seen the reverse where all hope gets totally destroyed and it becomes the work of the support group to dust the person off, get them back on their feet and in the fighting ring again
    As you say, while some doctors try too hard to keep pushing intervention treatments against the wishes of the patient, there are just as many who seem to randomly pick arbitrary numbers out of the air about the amount of life left to live.

    Those who remove all hope and give up on patients still fighting the fight, are most definitely not healers

    • Suzi Q 38

      Yours is a personal decision.

      All I have to say to that is BRAVO.

      Sometimes physicians give up when you do not want them to.

      Everyone is different. Each decision is unique and should be made by the person in charge…the patient.

      It should not be the other way around.

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