Monday, September 14, 2009

Do everything?

The room was darkened, the parents distraught, and the social worker was there as I knocked on the door of room 202 on the medical ward. My pager had buzzed me early that Sunday morning when I was on call for Pulmonary consults. The Internist asked me to see a 13 year old boy I'll call Mike who was dying. The abbreviated history was that of a previously healthy youngster who had a widespread metastatic osteosarcoma of the femur. The X-Ray showed multiple masses throughout both lungs. He was struggling to breathe even with an oxygen mask.

The amazing part of the story is that Mike had never been treated. There were potentially curative treatments which can involve chemotherapy and amputation. The parent's firm belief was that he could be healed by prayer and, not surprisingly, Mike went along. I must admit that I wasn't very happy about this consult because it seemed like there was nothing I could do and that I was just an impotent adjunct to a sad frustrating story.

Apparently early on, the medical team had tried to get a court order for treatment or at least have a legal guardian appointed who could be more of an advocate for appropriate medical treatment. None of this had been timely enough to prevent Mike's current rapidly downhill course.

He was thin, emaciated and pale. He gave me a weak smile and said that his main concern was trouble breathing. The lung exam showed abnormal crackling sounds and the heart rate was fast at 130 with a thready pulse. His pain was being well treated with narcotics. A respiratory therapist was making frequent visits trying aerosols with limited benefit.

As I began to talk about options for treatment for his breathing, I soon found out that no one had discussed the "code status" with Mike or the family. In other words, if Mike's breathing stopped or the heart beat ceased, would we do CPR? This was in 1974 before we had hospital ethics committees or talked about terms like futility. But it seemed clear to me that it made no sense to even offer CPR or a ventilator in the ICU in Mike's case. But the question was how to broach this with Mike and the family.

The social worker, nurse, respiratory therapist, parents and I met in the conference room nearby Mike's room. After introductions, I reviewed the medical facts and let them know that I thought Mike's remaining time was very limited perhaps hours to days. The parents didn't seem surprised. They had seen Mike go downhill but were still praying and hoping for a miracle. Then I talked about options and the notion of a ventilator came up. I was pretty candid with them that a breathing tube and standard mechanical ventilator would have potential harms in terms of suffering. Then the respiratory therapy had a suggestion for help, "Doctor, how about the Bird Respirator to support his breathing. This turned out to be a wonderful compromise. The family and Mike did not feel abandoned, the Bird Respirator was relatively low tech and did not require transfer to the ICU. A mask could be used for both this and the oxygen. Now days, this would be called non-invasive ventilation. The brilliant inventor, Dr. Forrest Bird who had helped save so many lives during the polio epidemics had given us the technology to help with palliative care for Mike.

Several hours later, Mike with Bird Respirator attached passed away comfortably. The parents felt that everything had been done and we're so grateful that no one chastised them on their belief in faith healing.

I did not offer transfer to the ICU or CPR. Medical futility is often difficult to define except in fairly extreme situations, and is debated often in the modern ICU, by ethics committees, and legal scholars.

When I discussed this case later with a colleague, he said "Sometimes you need to be an advocate for basically doing no harm while you're trying to relieve symptoms. You were doing the duty of a doctor."

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