Brittany Maynard, a death with dignity advocate, chose to end her life in early November. The news did not get as much attention as it should have, possibly because Ebola was the biggest issue of the weeks that surrounded it.
Her self-directed death by pills in Oregon, one of the few states in the U.S. with legal physician assisted suicide, made national news because she was young, attractive, willing to go public and very articulate. Her death and the circumstances surrounding it brought me to thinking about the lines between active and passive death.
As an ER doc and as a family doc, there was often conflict between the roles. As an ER doc, I was directed to and charged with saving the lives of strangers who happened to come in on my shift.
On the other hand, as a family doc, I developed relationships that lasted years and was directed and charged with helping patients navigate the health care system for their best benefit.
The lack of a good system, the subtleties of interpreting code status, and the legal issues for notifying the ER docs and emergency personnel of personal choices about end of life meant that often patients received more aggressive care than they wanted. How many of us have had to undo what was done in the ER because it was far more than the patient wanted?
An elderly patient of mine, with whom I had had the conversation recently about end-of-life decisions, ended up in the ER after a trauma. Both he and his wife had discussed with me that if he was unable to live a full and active life, they did not want aggressive medical treatment.
Shortly after that, something happened, and he sustained a high c-spine fracture and spinal cord injury, along with a head injury. He was brought to the ER in the middle of the night, intubated and I was called to manage his care.
It was highly unlikely that he would survive the initial 72 hours after the injury. If he did, given his age and the nature of his injury, he would certainly have been totally paralyzed, and probably ventilator-dependent the rest of his life.
After consultation with the neurosurgeon, confirming my opinion of his prognosis, I spoke with the family, and we extubated him. He died shortly after.
A nurse came to me and said, “You killed that patient.”
Where do we draw the line between compassionate care, respect for the family’s and patient’s wishes, and needless abuse by technology? When should patients be allowed to end their lives with dignity, surrounded perhaps by family at a bedside at home, versus connected with tubes and lines in an ICU, surrounded by strangers trying to maintain a set of numbers between normal parameters?
When do we kill a patient by acting, versus allowing them to die of a process that has already occurred, even if it means withdrawing care that will not change their prognosis, and perhaps extend their life by a few hours, days or weeks in an undesirable state? Where is that line?
I urge you to become aware of POLST and the need for advanced directives. Every patient we treat needs to have advanced directives, no matter how young, and POLST, when they face a clear end-of-life issue. And we and society need to guide the laws to adjust to the realities of our technology.