Heroic measures that come too late don't affect how people choose to live
By "angienadia," MD | in Physician
I sound harsh, but there was no better way to put it. I was taking care of Mrs. B, a 60-year-old lady with COPD who called EMS for shortness of breath. As EMS readied to take her to the hospital, she said, “You all are gonna have to wait until I finish my cigarette.” She has been intubated many times for COPD exacerbation, visited the ICU a hundred more times. She said if she got out, the first thing she would do would be to smoke a cigarette, but she did not believe she would make it this time. After multiple weeks on continuous BIPAP with spurts of intubations in between, she told us to quit and let her die.
Looking around the ICU that day, there were multiple stories like her – a cirrhotic who was actively drinking despite his varices bleeding to death after 30 units of various blood products that turned out to be futile, a 20-year-old diabetic with recurrent admission for diabetic ketoacidosis who left against medical advice the minute he found out he would not get any intravenous dilaudid, a gentleman admitted with pulmonary edema every 3 days because he refused to go to dialysis.
As days passed, I realized that these patients were common – I was being trained to undo what these people did to themselves, so that they can leave the hospital to do it some more. Some has hurt themselves so many times it could not be undone, despite many resources wasted and much money spent. I watched 30 units of blood passed through one end of our patient only to flow right out another, and I wondered if there was not someone else out there who would not undo our efforts, our blood products, our precious resources.
More importantly, I wondered if we could ever draw a line, where we say enough is enough, where we say you do not get a second chance at life so that you can just kill yourself in the end, where we say there comes a point when heroic measures cannot cure how people want to live their lives. Before medical school I always thought that medicine was made to promote health, but in the light of reality I have learned that my job in the ICU today is really to prolong death, so that in the end people can crash and burn a bigger flame, taking much needed resources with them.
Mrs. B knew in her heart that smoking would be her death, yet smoking was the one thing she pined for. I wanted to tell Mrs. B that if she wanted to die, I was in no place to stop her. I might have had a shot as her primary care doctor before she picked up her first cigarette, but that time is long passed. In the end when the BIPAP came off, she became unconscious and passed away peacefully. I wanted to ask if we should have stopped sooner, maybe two intubations ago, but I will never know.
“angienadia” is an internal medicine physician who blogs at Primary Dx.