Great post by the SDN legend:
Dawn of the Dead
November 24, 2006
Loaves and Fishes
The body of Mr. Dubois recedes into the shadows as the nurse turns down the lights. His family wants some time with him before he is taken wherever it is we take the bodies of those who finally exhaust our ability to reanimate them. Mr. Dubois did not go quickly or easily. His death has spanned months, if not years. The massive stroke which finally finished him off was just the last in a series of insults, all of which steadily whittled away at his intellect, his quality of life, but never the conviction of his family that he needed to be kept alive at all costs.
The details of Mr. Dubois' decline are familiar to anyone who has worked in an intensive care unit. Already in poor health from numerous chronic medical problems as well as mildly demented, he suffered a minor stroke and became bed-ridden. His wife, in poor health herself, was unable to transfer him from his bed to a bedside commode and his children eventually moved him to a nursing home where, with the exception of dialysis three times a week, he spent his days laying in his own urine. Over the course of a year he made several visits to the ICU where he was treated for pneumonia and sepsis, urinary tract infection and sepsis, sacral decubitus ulcers and sepsis, and finally a COPD exacerbation with pneumonia and sepsis. This lead to the final, massive stroke which should have finished him off except that after years of neglect, his family was still not ready to let him go.
They were perfectly willing to park him in a nursing home, you understand, as long as they didn't have to think about him. I'm sure they visited even if the visits eventually tapered off to a hurried fifteen minutes every other week, visits more to demonstrate that they still cared than to look after Mr. Dubois who lay in his bed literally rotting away both mentally and physically.
At the end the family didn't want Mr. Dubois to suffer, at least not while they were around. I'm sure they didn't lose sleep over the suffering he endured as an immobile piece of bodily-fluid producing meat in his fly-blown nursing home. But in the hospital, with the doctor and skilled ICU nurses it was all sanctimony and reverence.
The contracted, slack-jawed body of Mr. Dubois continued its leisurely spiral towards death as we used every expensive weapon in our arsenal and spent tens of thousands of somebody else's dollars in our absolutely inexplicable desire to play along with the family's delusions.
The family's delusions, like most, grew in isolation of the basic facts. I suppose if his family had taken care of him at their home as was the case for almost all of human history the story might be different. If they were the ones cleaning his bowel movements, spooning soft food into his mouth, or living with the rotten smell of ulcerating bed sores, one of which had eroded down to his sacral bones, they might have been relieved at his death, both for their own sake and his.
Nor did they give a thought to the cost of his many hospital stays, the total amount of which is almost impossible to calculate. Somebody else will pay, they always do. He's paid taxes his whole life, goes the mantra, so let Medicare handle it despite the fact that one week in the ICU probably ate Mr. Dubois' entire lifetime contribution to the system.
A day in the ICU costs several thousand dollars with only a minimal level of care. Then there are the many paid specialists continually consulted to tell us what we already know, namely that Mr. Dubois is dying. The nephrologists shakes his head sorrowfully over his kidneys. The cardiologist writes notes and orders expensive studies which reveal that his heart is bad. The gastroenterologist fails to discover the source of his frequent melanotic stools and the hematologist advises that even though his leukemia is going to kill him in a few weeks (guaranteed) we should go ahead and transfuse four units.
The vascular surgeon, the only realist in the bunch, when consulted for a possible repair of Mr. Dubois' dangerously bulging abdominal aortic aneurysm says, "Are you ****ing kidding me?"
Too bad he can't write that in his consult note. The dry precision of medical prose gives the illusion that we are in control of Mr. Dubois and could turn him around with a little coordination between the medical specialties. The family certainly buys into this notion. Aren't all of his medical problems being managed? Don't doctors have all the answers with their extensive education and big words? Surely all of those monitors, pumps, and flashing lights must be doing something. We're not asking for loaves and fishes here, doc. Just keep his heart beating.
So that's what we do. In the end all we are really doing is giving the house staff valuable experience running ACLS codes. We get a carotid pulse back and beam with pleasure at the good thing we have done despite the fact that it is taking three different pressors to keep his blood pressure compatible with life and to remove any one of them will be the end of Mr. Dubois. What we've really done is paint ourselves into a corner. He is never coming off the pressors. In about a day, if he lives that long, Mr. Dubois' toes and fingers are going to start rotting off.
Perhaps then we can withdraw support, if it's all right with the family that is.
http://www.pandabearmd.com/2006/11/24/dawn-of-the-dead/
