Thursday, August 8, 2013

Allowing a Patient to Die - Yes or No?

I was recently invited by KUOW's Katy Sewall to be interviewed about the use of ventilators in the ICU .

In the interview I note two patients.  Both begged to be taken off the ventilator and die.  In one we followed his wishes, in the other we didn't.  In another patient, the family begged to stop; yet in another a family begged to continue.  Death thus becomes a negotiated event in the modern ICU - a real tour de force in applying the ethical principles of autonomy, do-no-harm, and beneficence.

In the back of my mind during the interview was a recent lecture from Coursera (free on line) where they were tying to define death.  It used to be pretty simple - when the heart stops you die.  Well, with new interventions such as hypothermia, a higher percentage of patients are surviving than the current rather dismal 15%.  So they simply stated, that death really is defined by when we stop resuscitation!  I can see from an EMT or ER physician's training that this would be their focus, but the vast majority of us simply have the dwindles from old age sometimes complicated by cancer or heart disease or dementia.  For the frail elderly, CPR rarely works and many patients have standing orders to prevent the terminal assault of chest compressions and electric shocks.

But it's not always straightforward in the ICU in terms of the ventilator.  It's the system support of last resort, bringing oxygen into the lungs and getting rid of CO2.  When everything else is failing we need to talk about the ventilator.  Is it really helping or just prolonging dying?  About 70% of all deaths in the ICU are from withdrawing the ventilator.  Everything else has been tried.  It can be a bumpy road in shared decision making for families and physicians.  Letting go is often the right thing to do, but it's never easy


1 comment:

  1. Many thanks for sharing. IMHO, while it's terrific to encourage discussion and shared decision-making on the topic of about end of life wishes, often left out is that talking can't always (or maybe even 'often cannot') avoid bumps in that road. And that being able to 'let go' doesn't mean it's easy. I'll link to your fine words on www.bestendings.com

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