Atul Gawande is on the right track (read this now)

I'm running late for sleep the night before yet another 30+ hour shift in the ICU so for now I'll just post a link to this perfectly timed New Yorker Magazine article by Atul Gawande. In it, he eloquently addresses the important question of what medicine should do when it can't save a patient's life. It's a question that most of us will at some point have to answer for ourselves, or more likely for a loved one.

One of my caught-in-limbo patients prompted his internist to strongly recommend the article to me. Atul Gawande + the New Yorker + end-of-life care obviously means that this article is required reading for all. Please check it out and consider what you would want for yourself or your spouse, mom, or sibling. Then take the next step and share your thoughts with your loved ones . It is difficult to initiate this conversation -- as it was even for death-and-dying expert Dr. Susan Block when she had The Conversation with her father -- but it's better to consider and discuss this question with loved ones before a critical need to respond arises.

A Pulmonary & Critical Care attending physician recently explained that people don't want to die at home anymore. He said most people want to die in the hospital instead. I refrained from openly contradicting him given our quite formal relationship and because he seemed so satisfied by his conclusion, but I think his Critical Care perspective leaves him heavily biased. As far as I can tell, families bring their loved ones to the hospital at the end of their lives with hope that medicine will offer life-prolonging therapies. Thoughts about quality of life don't really enter their minds until later, when the acute emergency has passed and it becomes clear that medicine won't offer the fresh start they seek.

Gawande briefly addresses the subject of admitting people to the ICU near the end of life:

In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions...Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or “It’s O.K.” or “I’m sorry” or “I love you.”

Atul Gawande, in "Letting Go," New Yorker Magazine, August 2, 2010

His words sum up the experience of a sizable proportion of my patients in the Intensive Care Unit so far. At times it seems nearly criminal that our efforts to "save" clearly terminally ill patients manage only to extend their suffering.

What's more, we do a poor overall job of providing comfort care, despite having a certified Palliative Care Nurse Practitioner on staff in our ICU. There is even wide variation in how often different nurses decide to give the "as needed" medicines to address pain, anxiety, and shortness of breath. Some give every 2 hours on schedule and consider it a failure if the patient wakes up. Others give more judiciously but delay administration when they get bogged down in myriad other duties.

I've even seen a couple of nurses completely withhold pain medicine because they were concerned about an actively dying patient's low blood pressure. He spent several hours in distress and was relatively uncomfortable during most of the week before his death. Surely hospice-based care or even just an overall palliative care strategy to address goals of care would have been a more effective option than spending his last days in an intensive care unit not set up to provide true comfort care. I feel I failed him despite my efforts to provide ready access to comfort measures.

I'll post more about my ICU adventures when I can -- it's definitely the most interesting, educational, and thought-provoking time in my medical education and training so far.