In my second year of residency, I was on the hematology/oncology service where we were taking care of a pleasant lady in her 80s who was admitted with pancreatic cancer. It was apparent that the disease had spread rapidly, and when we discussed her at rounds, we knew that she likely had a few months to live, at best. We also knew, however, that there were life-extending treatment options we could provide. When we walked into her room and presented these to her, she was attentive and listened respectfully, and she ultimately decided not to pursue any more treatment.
What struck me was how content she was with the decision and how no objection was made by the oncologist. Surely, such a decision in terms of choosing to ultimately die instead of prolong one’s life required more discussion than this (or so I thought). But, just like that, the decision was made, and the conversation was over. With all the questions that came to my mind regarding the patient’s acceptance of her mortality and our decision not to push her treatment, I wished at that moment that there could be easy answers. None came. Instead, I started thinking about the role of patient autonomy and the physician’s role at the end of life. And then, even more questions started to rise.
Was it OK for us to allow the patient to decide not to continue life-prolonging treatment? When it came to her impending death, was it right for us to just allow it to happen without any other medical interventions? Was it cruel of us not to facilitate the patient’s death, especially if the patient was in pain? Were we playing God by even thinking ourselves suitable to make a decision regarding the timing of a patient’s death? Were there particular beliefs that I had that guided my thoughts about this, and if so, was there a valid basis behind these beliefs? These questions, and many others, kept coming to me, and a period of true soul searching occurred. I ultimately realized that my Christian beliefs formed the basis of how I saw this issue. For all the teaching about focusing on the facts of medical care, I couldn’t shake off my beliefs when it came to this topic. In confronting death, the questions are metaphysical. For people like me, a religious worldview provides a way to navigate this tricky subject.
The medical community has been dealing with this subject for some time now, and various perspectives lend themselves to the conversation. As patients approach their final days, the discussion shifts not only to their comfort but also to the process of death. The debate has historically been whether physicians should take a passive versus an active role in this process. Certain organizations, like the American Medical Association, suggest that the role of a physician at the end of life should be passive, and that any active participation in the death of a patient would go against our role as healers. However, another perspective is that it would be cruel for physicians not to actively participate in facilitating the death of a patient who was suffering painfully from a terminal illness. This perspective is shared by philosophers such as James Rachels and Margaret P. Battin, and patient autonomy is the genuine concern. Now that certain states allow for medical aid in dying and others are potentially looking at this issue in the ballot box, there will certainly be more public discussions on patient autonomy and aid in dying.
Inevitably, the debate asks us to look at the process of death in general and whether there are other implications with regards to our role in that process. Across the board, regardless of one’s philosophical or religious worldviews, we consider death to be a very profound experience, not only for those who are about to experience it, but for other people connected to it. The profundity of it brings about metaphysical questions that are not easily answerable, and, as a result, it can become quite personal. Various perspectives about God, the afterlife, human suffering, and other things can come into play that force us to confront our personal worldviews. As physicians who are trained to be objective, this can cause serious discomfort, since our answers to these questions can feel so subjective. But it is important for us to be honest with these questions. I know that my Christian worldview will move me more toward one perspective, whereas someone else’s may move them in a different direction. If we are honest about our worldviews and appreciate others, we can have a fruitful dialogue about our role at the end of life.
As I continue to encounter these situations, I feel that my perspective has changed. Before, I worried about whether I was rushing discussions about end-of-life care and whether I was making the right call to tell patients and their families that further medical care was futile. With the understanding that potential life-sustaining measures could be stopped based on what I told patients and their families, I wanted to make sure that the judgment call I was making was a good one. One of my beliefs is that God is the author of life, and by extension, the One who ultimately determines the time of a person’s death. With this belief guiding some of my perspectives on end-of-life care and patients’ final days, I hoped that, in these tough discussions, I was making a decision that was close to what God would have wanted. It’s a powerful responsibility to determine when it’s medically unfeasible to continue life-sustaining measures. That responsibility has periodically brought me to my knees in private as I thought of the spiritual perspectives that were connected to how I approached these conversations.
Now, my perspective focuses more on preserving the dignity of the patient in his or her final moments. I think it’s lost upon us frequently, but we need to take a step back and realize that we are one of the last people that these patients will see in their lives. Frequently, we become a part of one of the most personal experiences a person will ever go through as they confront their own mortality in a real way. In these moments, they are looking for hope, mercy, love, and compassion — things that my Christian faith teaches me to extend to others at their most difficult moments. Rather than thinking that this is just the job of their family members, maybe we should realize that we can provide these things to them in their final moments through how we care for them. I think many people will agree, irrespective of personal worldviews, that we should have hope, mercy, love, and compassion guiding how we care for patients in their final moments, out of the hope that their final days on this Earth will be peaceful ones.
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