“Death comes for all of us…Most lives are lived with passivity toward death-it’s something that happens to you and those around you…but [we] trained for years to actively engage death, to grapple with it…and, in so doing, to confront the meaning of a life…The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.” (Kalanithi, 2016)
In his book, When Breath Becomes Air, Paul Kalanithi, a senior neurosurgical resident faces his own mortality after years of staving off the death of his patients. His book raises the question: What is our role in patient death as a physician? With modern advances of pharmacology, oncologic treatments, surgical technology, and medical devices, it would appear that we are trying to prevent death at all costs. But what about those costs?
As a family physician with a special interest in palliative care, I witness the frustration that can occur when we are faced with a patient with an incurable illness. As a result, we try to manage and reverse it. Take for example the case of Jane, a 50 year old woman with advanced early-onset dementia who is diagnosed with a biliary duct obstruction from a pancreatic cancer. Is there a fixable problem? Yes. But should we fix the problem? No one asks the latter question and Jane is rolled into the OR. There’s also Doug, a 67 year old man with lung cancer who is admitted for a pneumonia that is not responding to oral antibiotics. He is admitted to the ICU for vasopressors to keep his blood pressure up and IV antibiotics to try to fix the pneumonia. Doug passes away 3 weeks later, in ICU hooked up to 2 monitors, 3 IVs, 1 central line, and a BiPap machine. These interventions may have prolonged the lives of Jane and Doug, but would they have personally chosen them if they were made aware of the price to pay for the time gained?
What if death is not the enemy? What if anything that affected both the quality and quantity of life were made the enemy. This could include both diseases and our cures. Tom is an 85 year old man with a severe ischemic stroke resulting in sustained hemiparesis and difficulty swallowing. He is at high risk of contracting aspiration pneumonia if he is allowed to eat, and so he is denied any food for his safety. Tom asks if he can eat a hamburger. A family conference is held, and his family is made aware of the risks of his request. Tom enjoys multiple homemade meals before he passes away a few days later. His family wonder if they did the right thing and question the doctor’s decision to allow him to eat, but Tom already said what he wanted. He wanted to live until he died. And to him, living meant having a hamburger with his family.
Just this past week, a patient with liver cancer was admitted for a viral pneumonia. His distressed family requested something more for his dyspnea as they watched him struggle. As he reaches out gasping for air and restless from hypoxia, the family is told there is nothing more than can be done without risking his life.
A physician must really ask themself, are we truly battling against death? It may happen regardless of what is done, but it is our patient’s lives that we can truly impact. Near the end of the journey with a life-limiting illness, the interactions with health care matter most. As death nears, health care decisions can have a dramatic effect on how our patients and their families remember the last days. The issue of medical assistance in dying is far too complex for the scope of this article. But there is no question: When our patients are dying, they need our help more than ever.