“Got a new admission for you. 93-year-old male with end stage kidney disease on dialysis, coronary artery disease, hypertension, diabetes, peripheral vascular disease here after being found unresponsive. Oh by the way, I think he’s DNR/DNI.”
It’s like music to the ears of any medicine resident. I’m still not entirely sure why this phrase brings such relief, but I’m in my last year of residency and still exhale a little bit easier when I hear it. Maybe I’m still acutely aware of my shortcomings as a physician. My pulse still goes up dramatically when I see a patient going the wrong way. Will I make the right decision? Can I save this patient?
It’s a lot easier to consider these questions when I know the patient has already contemplated the end and is OK with what could happen. Less pressure on a young physician still sweating his way through rounds.
Then again, I’ve seen enough now to differentiate a good death from a bad one. I’m a young man, but I’m envious of the patients that I have seen die a peaceful death surrounded by their family and friends. Physicians are famous for avoiding rooms when death is imminent, but I’ve found myself drawn to rooms where death is expected and even embraced. These patients have shown me how the end of life can be a time of wonderful reflection and joy. That’s definitely something I personally want, and the vast majority of my patients seem to want that too.
My new experience as the code team leader last year has also shown me what I don’t want. Running codes on patients with terminal disease and no hope of recovery is probably one of the most demoralizing situations in medicine that I have come across in my short career. You can see it in the eyes of the entire code team while everyone dutifully performs their role. Why are we resuscitating this patient? What are we accomplishing? These are hard questions with no easy answers.
Ultimately, I’ve found that contemplating death is something that is paradoxically not best done in the ICU. By the time I am standing over the patient that is gasping for air and asking if they really want me to intubate them, the ship has already sailed. My colleagues and I used to comment amongst ourselves about how we wish someone had addressed this with them sooner. I now grow quiet when others talk. I think about my clinic patients that I have failed to talk to about the end of life. Can I smile just as much about asking my 83-year-old patient if she ever wants chest compressions as when I ask if she can still keep up with her grandkids? As a physician, it is my duty. As a human being, it is much more.
And so I write this more to myself than any other primary care providers. Have the conversation. Find out what your patient wants. No other physician has the relationship with him or her that you have. Don’t leave it to a hospitalist or intensivist who is just meeting the patient and doesn’t know how she sneaks candy to her grandson every Sunday. Worse yet, don’t leave it a resident like me holding the endotracheal tube for the first time. Saving them from my trainee exuberance may be the best outcome of any conversation you ever have with them.
Robert Glass is an internal medicine physician who blogs at HumorMD. He can be followed on Twitter @HumorMD.
