When the best care is a comfortable death

I am no stranger to death. I have gently closed the eyelids of a woman dying from liver disease, blasted Led Zeppelin by request during a man’s last breath, and exchanged dog photos with an elderly gentleman on his final day. Although I cared for these patients deeply, our relationships were defined by illness. Ms. B was different. Healthy and curious, she had sat in my clinic countless times with her blue cardigan and trembling hands. She was my patient, and I was her primary care doctor.

Recently, Ms. B died from complications of COVID-19. “She died comfortably,” the hospital physician reassured me. Only at these words could I finally relax. I did not want to hear, “We did all we could.” I did not want to imagine a swarm of bodies descending upon Ms. B, smashing her ribs as they attempted to pump life into her fragile body. At her age, she would be unlikely to survive the resuscitation. Moreover, that is not what she wanted.

Months ago, I met with Ms. B to have an honest conversation about end of life care. Together we filled out a Physician Order for Life-Sustaining Treatment, or POLST form, which would act as a set of medical orders if Ms. B were hospitalized. The two ends of the treatment spectrum are “full treatment” vs. “comfort measures”. “Full treatment” refers to prolonging life at all costs. This includes interventions such as chest compressions and breathing tube placement, even if it is physically painful and may lead to long-term disability. “Comfort measures” focuses on symptom control and pain management rather than prolonging life. Ms. B firmly expressed that she had lived a full and remarkable life. At her death, she did not want to suffer. She declined all invasive procedures, electing for “comfort measures.”

When Ms. B arrived at the hospital last week, lime green POLST form tucked in her chart, the physicians knew what to do. They treated her pain and symptoms, keeping her comfortable until her death, just as she desired.

Nationally, only about one-third of Americans have advanced care plans. This means that the majority of patients and families are forced to make decisions about life and death during critical moments. An important part of primary care is discussing end of life care with our aging patients. However, physicians do not carry this responsibility alone. Speaking as a daughter, granddaughter, and sister, I believe everyone should have these conversations with their loved ones. In the anxious climate of COVID-19, it may seem perverse to create a template for death, but this is exactly what many physicians across the country are doing for their own families. I argue that now, in a time of global uncertainty, it is imperative to assess our goals if the worst were to happen. By exploring our value systems and treatment goals, we can minimize unnecessary pain and proactively create a plan that speaks for us even if we cannot speak for ourselves. In Ms. B’s case, it would not have been heroic to place a breathing tube and cause pain, when her ultimate wish was to pass peacefully.

During this process, we must also consider human autonomy and often rapidly changing circumstances. POLSTs are living documents that should be updated regularly, and the patient has the ability to change their mind at any time. If anything, the active contemplation of our ideal quality of life, hopes, fears, and wishes is more important than completing the form itself.

We cannot forecast the future of our patients or loved ones. I could not predict that Ms. B would ultimately die from a global pandemic that has killed nearly 800,000 individuals worldwide. However, we can advocate for the ones we hold dear, by helping them chart a path that aligns with their goals of care. And sometimes, the best care is a comfortable death.

Jessica Lu is a family medicine resident and can be reached on Twitter @JessLuMD.

Image credit: Shutterstock.com

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