Choices

Mr. R is a 67-year-old Army veteran with metastatic lung cancer admitted with shortness of breath. His chest x-ray shows progression of his lung cancer. Three days ago, at his last appointment with his oncologist, he had been told that further aggressive treatments would not help him, and hospice was recommended. The idea of hospice had been brought up many times before over the course of his illness, but he was still unable to commit to it. He said he would continue to think about it. The day of admission, it appeared as though he would soon require mechanical ventilation for respiratory failure. The admitting resident discussed goals of care with the patient and his wife for 45 minutes. Despite understanding that his illness was severe and likely irreversible, Mr. R expressed a desire for aggressive care, including intubation and mechanical ventilation if necessary. The intensive care unit was consulted, and another resident from the ICU came to speak with the patient. Upon walking into the room, he asked the patient if he "wanted to die with a tube in [his] throat." Mr. R said no. A few minutes later, the resident walked out and signed the “Do Not Resuscitate” form. As a medical resident, I am expected to discuss code status with every admission - from the 20-year-old basketball player presenting with mild acute kidney injury after a tough practice to patients like Mr. R. Most of the time, these discussions are easy because the patient's wishes make intuitive sense - the man dying of cancer expresses his longstanding wish that he be allowed to die naturally, the woman with the heart attack wants to be resuscitated but not maintained on a ventilator if there's no hope of recovery. Occasionally, these conversations are slightly more difficult. In Mr. R's case, it just did not make sense that he would want to be intubated and mechanically ventilated because the process causing his respiratory failure could not be reversed – he was going to die in the ICU, sedated, on a mechanical ventilator. It was still more difficult because he said explicitly that he did not want to die that way, but, in the next sentence, insisted that he wanted to be intubated even if there was no chance that he could ever be extubated. He was genuinely conflicted. I spent 45 minutes with him trying to tease out these conflicts. At the end, I was able to make some sense of it – he didn't want to die on a ventilator, but more than that, he wasn’t ready to die. So even though it was hopeless, and even though dying in the ICU, sedated, on a mechanical ventilator was not how he wanted to die, he wanted to be intubated and mechanically ventilated. At the end of our conversation, I knew that Mr. R understood the consequences of both options and I felt confident that he could decide. It didn't really matter whether I thought his choice was right; he was the one that was dying. A short while later, after the ICU resident’s visit, my conversation with Mr. R no longer mattered. As far as the resident cared, he would not be intubated. And as much as I knew that Mr. R's death would be much more pleasant without a breathing tube and a long ICU stay, the whole thing felt wrong. I felt that Mr. R had been conned into changing his code status and that I had failed to stand up for him. More and more, experts emphasize that patient-centered end-of-life decision-making does not mean that patients should be presented with a menu of end-of-life choices and asked to pick. Rather, they say, physicians should take patient values into account when recommending a path and seek the patient's understanding and agreement. These recommendations seek a middle ground between the 1970s' paternalistic approach to end-of-life decision-making and an approach that leaves patients facing these difficult decisions without guidance.¹ It makes sense intuitively that patients would expect to be guided by experienced physicians through the dying process; in one cohort study, only one in six seriously ill patients wanted to make difficult decisions on their own.² In Mr. R's case, the ICU resident's approach to recommending one path over another struck me as sneaky and unfair. But ultimately, my colleague wanted to help Mr. R die the way he wanted to die. Where I looked at Mr. R's internal conflict and saw someone who needed more time, my co-resident looked at the same thing and saw someone who needed his mind made up. Luckily, Mr. R's deterioration slowed and he never required mechanical ventilation. The next morning, he and his wife opted for home hospice. But for me, questions remained. Was I wrong not to push Mr. R harder toward comfort care? Was my colleague wrong for presenting an ugly (if true) picture of what the end of Mr. R's life could have looked like with aggressive life-sustaining treatment? As often as I discuss code status with my patients, I still have so much to learn. For more senior attendings and physician-scientists, there is an opportunity to teach and model appropriate ways to guide patients in making these tough decisions.  

1. Lammas D, Rosenbaum L. Freedom from the tyranny of choice – teaching end-of-life conversation. NEJM 2012;366:1655 Pubmed
2. Heyland DK, Tranmer J, O’Callaghan CJ, Gafni A. The seriously ill hospitalized patient: preferred role in end-of-life decision making? J Crit Care 203;18:3. Pubmed