End of life discussions are hard enough

I posted this several years ago. I think that it is worth posting again.(Besides, I don’t know what to make of Rick Santorum.)

When Sarah Palin wrote, “the America that I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s ‘death penalty’ so his bureaucrats can decide, based on a subjective of judgment of their ‘level of productivity in society,’ whether they are worthy of healthcare. Such a system is downright evil,” I got physically nauseated. The only reason that former Governor Palin said this was to derail healthcare reform and to try to elevate her own status in the conservative movement. The statement had no basis in reality. My nausea stems not from a lie, but from this person unknowingly making my job harder. Speaking with real patients about real end-of-life issues is incredibly difficult.

The following is an example of an end of life discussion. It has been fictionalized to protect patient’s privacy. A 80-year-old man presented after a fall at home. The patient had been in declining health for some time. He has an abnormal heart rhythm and congestive heart failure. He is on blood thinners because he is at increased risk of developing clots in his heart. The patient is awake and alert on arrival. A CT scan is obtained of his brain which reveals blood between the brain and the skull — subdural hematoma. The patient is admitted to the intensive care unit for observation. Medications are given to reverse his blood thinners. The patient does well overnight in a repeat CT scan (standard practice) performed to see if anything new has shown up. The patient has a new contusion (bruise) on his temporal and frontal lobes.

The patient, who was lucid throughout the night, is now somewhat confused. He is having some problems finding his words. His son, who is an orthopedic surgeon, had been with the patient through the night. The son is now extremely concerned. He wants to know what happened. I review the CTs with him and point out that the contusion is in the area of the speech center of the brain. This should explain his difficulty finding words.The son wanted a repeat CT scan, in spite of the fact that the second scan was only completed four hours ago. I asked whether, if we find a surgical lesion (something that can be operated on), he would like me to call a neurosurgeon. I asked if he wanted his father to undergo brain surgery if it is necessary.

I think this question is more than reasonable. Thankfully, the son never had to make that decision. The repeat CT scan was the same as the second scan. Neurology was consulted. Over the next several days, the patient slowly improved and was able to be discharged to a rehabilitation center.

You know our society is in trouble when a physician has not thought about end-of-life issues concerning his 80-year-old father who has a bad heart. From a medical standpoint, I just want to do what is right for the patient, which is to follow that patient’s wishes. Yet so very few families have talked about end-of-life issues. You don’t want to be in the position of the son where you’re having to make a decision while looking at a CT scan in the middle of an ICU. Instead, you would like to be able make decisions in the privacy of your physician’s office.

I deplore any politician that makes this situation harder. Emotions are overwhelming when families are faced with these types of decisions. Exploiting end-of-life issues for political gain should get those politicians a special place in Dante’s Inferno.