Some­thing I learned as a medical intern is that there are worse things than dying.

As I recall, it was sometime in April, 1988. I was putting a line in an old man with end-​​stage kidney disease, cancer (maybe), heart failure, bac­teria in his blood and no con­sciousness. Prince was on the radio, loud, by his bedside. If you could call it that – the uncom­fortable, cur­tained com­partment didn’t seem like a good place for resting.

An attending physician, a smart guy I respected, approached me as I com­pleted the procedure.

“It’s kind of like Dante’s seventh circle,” he noted.

Indeed. A clear, flexible tube drained greenish fluid from the man’s stomach through his nose. Gauze covered his eyes, just par­tially. His head, hands and feet swelled with fluid. A semi-​​opaque hard-​​plastic instrument linked the man’s trachea, through his paper-​​taped mouth, to a noisy breathing machine. His skin, barely covered by a stained hos­pital gown, was pale but blotchy from bleeding beneath. An arterial catheter inserted by his wrist, just where I might have taken his pulse had he been healthier. A fresh adhesive covered the cotton gauze and brownish anti-​​bacterial solution I’d placed over his lower right neck.

“Yeah,” I said as we walked out of the room to review another patient’s chart.

I won­dered if the ICU staff would mind my changing the radio station, just in case the patient could hear but not tell us he pre­ferred WQXR.

“There’s no way I would let this happen to me,” I remember thinking.

—–

This month, a report in the ACS journal Cancer indi­cates that most U.S. physi­cians don’t talk with their patients about end-​​of-​​life issues until death is imminent, if they do so at all.

The study, based on can­vassing over 4000 doctors who care for cancer patients in Cal­i­fornia, North Car­olina, Iowa and Alabama revealed that only a minority of physi­cians would raise the subject of a DNR (do not resus­citate) order or the pos­si­bility of hospice care for a patient with metastatic cancer with a life expectancy of 4–6 months. The article has gen­erated con­sid­erable, appro­priate attention in the press and for good reason – it bears on health care costs, patients’ rights, doctors’ com­mu­ni­cation and time con­straints and a host of points rel­evant to the practice of med­icine in 2010.

For pur­poses of this post, today, what I’ll say is this much:

Don’t wait for your doctor to talk to you about death and dying. Be proactive about your wishes and the kind of care you wish to receive, espe­cially if you’re sick with a serious medical con­dition. Take the ini­tiative – doc­ument your end-​​of-​​life pref­er­ences as best you can, according to the law of your state, and tell your physi­cians about any limits you’d like to set on the care you might receive.

It’s a con­ver­sation worth having, early.

——-

Here’s a very-​​partial list of resources for people who’d like to learn more about advance direc­tives, living wills, DNR orders, hospice care and other end-​​of-​​life concerns:

Med­linePlus on Advanced Direc­tives

New York State: infor­mation on Health Care Proxy forms and DNR orders

Family Care­giver Alliance on End-​​of-​​Life Choices

Hastings Center on End of Life Issues

American Hospice Foundation

Cisely Saunders Foundation

Hospice Foun­dation of America

The National Hospice and Pal­liative Care Organization

Elaine Schattner MD is an  trained oncol­ogist, edu­cator and jour­nalist who writes about med­icine. She teaches at Weill Cornell Medical College.  You’ll find her blog, where this post first appeared, at Medical Lessons.

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6 Responses for “How to Avoid Death in the ICU”

  1. steve says:

    The number of procedures we do on patients with no chance of cure or recovery is depressing. Many offer no chance of comfort or symptom relief, often on patients who are completely demented.

    Steve

  2. sr says:

    I hope that old people will no longer be tortured in the near future. Not only do you need to talk to your doctor, you also need to talk to your family. And doctors need to encourage their patients to talk to their families so family members are comfortable about these decisions, also.

  3. Zeltiq NYC says:

    Thanks for sharing this great article! That is very interesting I love reading and I am always searching for informative information like this.

  4. Barry Carol says:

    “The number of procedures we do on patients with no chance of cure or recovery is depressing.”

    Steve –

    Why is this? Perhaps you could comment on the relative importance of the following factors:

    1. Do everything is the default protocol if there is no living will or advance directive and no family member to make decisions on the patient’s behalf if the patient can no longer communicate or is not competent.

    2. The patient wants you to do everything.

    3. The healthcare proxy wants you to do everything even if the patient may not but can’t communicate that fact.

    4. There is a living will calling for no heroics but the family member can’t find it or the hospital lost it or the doctor(s) overrode / ignored it.

    5. Doctors haven’t leveled with the family or held out false hope when asked for an honest prognosis.

    What would you recommend to reduce the number of procedures performed on (to) patients with “no chance of recovery?”

    • JJ says:

      I have given the hospital and doctors my advanced alternatives, and they say they put them in the computer which is now linked to a large computer medical record system, EPIC. But when I go in for something a test or procedure, they always ask me if I have this and that it is NOT in the Medical Record system. This is scary to me as I live alone and no family around and I want these wishes to be instilled, and I see in teaching hospitals that a lot of the patients are treated like diagnosis and not humans with feelings. And each resident goes in and asks the same thing giving the patient a different answer. How frustrating for the patient, I work in the system and they tell me if they can that they don’t know what is going on as there are so many doctors seeing him with different answers. How crazy has this system become.

  5. Rob N says:

    Barry’s question #1 is a problem I see regularly at my hospital. It is the default and therefore causes a lot of extra cost with little or no benefit. We try hard to obtain living wills, but many patients show up already incapacitated and unable to fill one out. A great question, with no current easy answer.

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