In his soulful book, How We Die: Reflections on Life’s Final Chapter, the late surgeon and author Sherwin Nuland describes one of his patient encounters as a medical student. The patient, a 50-year-old man, presented to the hospital after a heart attack.
A few hours later, the patient suddenly collapsed pulseless and unconscious.
Training in an era when there was no defibrillator or CPR, the author notes:
For reasons I cannot explain to this day … I decided to act … What I was about to attempt seemed a great deal less risky than letting a man die without at least trying to save him. There was no choice.
I made a long incision from his breastbone around as far back as I could … to allow my hand to squeeze inside and grasp what I expected to be his silent heart … I took up his poor twitching heart as gently as I could and began cardiac massage. I stepped back from the disordered carnage … sweat pouring down my face … shouting, demanding that he live, screaming his name into his left ear as though he could hear, weeping all the time with the frustration of my failure and his.
His resident, having heard his screams, entered the room to see young Sherwin covered in blood, hands shaking from his first encounter with life escaping from within his grasp.
What the resident said next came to define his relationship with death as a physician: “It’s OK, buddy – it’s okay. You did everything you could. Now you know what it’s like to be a doctor.”
Doing everything we can. For as long as physicians can remember, this phrase has defined the passion within medicine.
After all, modern medicine owes its progress to this primal desire to “not go gentle into that good night.” Progress would have halted if providers ceased to ask, is this really all that we can do for this patient?
We have to acknowledge the meaning of “everything” has changed fundamentally, especially in recent years. Fifty years ago, it used to capture a sentiment of not giving up, more than it suggested actual interventions or options. Dr. Nuland’s encounter perfectly summarizes the abruptness and the finality of death that dominated medicine for years no matter what we tried.
However, progress in medical knowledge over the years has challenged and expanded the definition of this phrase dramatically.
There are now life-sustaining technologies available for virtually every type of organ failure with the exception of the brain, at least for the time being.
Before the invention of defibrillators in 1930, dangerous arrhythmias were almost invariably fatal. Now, the technology has evolved to the point where rhythm can not only be shocked and reset but also monitored constantly and dictated — all by a small implantable device.
The first dialysis machine for end-stage renal disease was not constructed until 1943. Now, nearly half a million people in the United States alone are dependent on dialysis for survival. We utilize ventilators daily to keep the patients alive whenever their respiratory functions are compromised. We’ve conquered the mechanics of breathing and can manipulate it to optimize the levels of oxygen and carbon dioxide in our bodies. Recently, we have begun to use powerful heart and lung bypass machines to keep people alive even when they have severe cardiopulmonary failure. As this platform continues to improve, one day soon we will have the ability to keep the body “alive” indefinitely.
As a cardiothoracic surgery resident, when I listen to patients, family members, and health care providers say, “We need to do everything we can,” I cannot help but feel moved by these words. It is a powerful plea, a reflection of inevitably being human — that tenacious will to resist death without giving up.
As providers, we have the duty to ensure that our patients understand what it means when we try everything, as its meaning constantly evolves. Most of our patients and their families are not familiar with the life-prolonging therapies medicine holds within its arsenal. Current technologies are now capable of prolonging “life” even in the absence of other qualities that we consider vital to living such as being awake, able to speak, move or eat. “Life” can be preserved even in the presence of conditions that render it miserable such as intractable physical or psychological pain.
In other words, these technologies have created a state of existence in between living and death. As technology further evolves, this gray area will only widen. “Doing everything we can” for our patients and loved ones can commit them to this in-between without any hope for return to normalcy.
There will always be additional therapies, drugs or devices we will feel compelled to add on simply by the condition of our being human, simply because we can.
But while doing more may create the illusion of doing good, some of them will not be productive, and some may even extend suffering. In those instances, we have to vigilantly remind our patients, their families and ourselves that each therapy comes with consequences, and should be initiated with full awareness of what it may entail and come to an unequivocal agreement.
As medicine progresses, death will only become a longer, and less defined realm. We are entering an era where people no longer die, but are weaned from living.
In this new context, “doing everything that we can” cannot remain the default, and as physicians, we must lead this change. Unlike before, it requires nuance and wisdom to know when life ends and death begins. Families may have difficulty finding closure until they have tried everything. They may feel as if they have given up if they do not exhaust every option. Without our willingness to engage in these conversations, how can patients and their families who are unfamiliar with our technologies navigate through these difficult decision-making processes?
While we engage with patients and their families in the already overwhelming and challenging discussion of end-of-life care, we must find the tenderness to acknowledge their fears. But we must also find the clarity and firmness to define what everything entails, and ask if everything should indeed be done. Be explicit about the odds and the possible degree of recovery. Above all, ask them and ourselves at which point of trying everything will we be able to find peace and acceptance of death.
Most importantly, if patients and families still choose to do everything after these conversations, we must remain by their sides and keep trying our best to compassionately find a way forward.
Because unlike the god-like technologies that prolong life and continue to change the scope of medical practice, our commitment as physicians to “doing everything that we can” to be present for those in pain and suffering has not changed and never will because that. More than any life-saving therapy, it is ultimately the real truth behind what it means to be a doctor.
Jason J. Han is a cardiothoracic surgery resident.
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