What Residency Looks Like XXXXV: Dying a Good Death

GoComics appears to have changed their permissions, because I can no longer save a comic to my laptop as an image file in order to be uploaded elsewhere. So go look at this Pearls Before Swine strip about Old Man Johnson coming home from the hospital to die and come back to read the rest of the post. I thought of it after a recent Morbidity & Mortality Conference by my Internal Medicine residency program. Due to M&M rules, I cannot share the case that was discussed, but I can muse about one of the themes that came up.

What is "a good death"? Americans have said time and again that they want to die at home, surrounded by their loved ones. However, most of them will die in an institution such as a nursing facility or a hospital. Usually this is because they are too sick at the end of their lives to be outside medical care. It is hard to tell whether this pneumonia will be the one that finally kills an elderly person, or whether they will walk (or roll) out of the hospital or skilled nursing facility in a week or two. So we treat every pneumonia until it becomes the last one. That's the one that looks like futile care and wasted healthcare resources.

It is even harder not to start the momentum of modern medicine: who would not give CPR to an older gentleman enjoying dinner at a restaurant with his family? But as bioethicist Elizabeth Reis shared, she now realizes she should have stopped those well-meaning strangers from trying to save her father's life. Only the night before he had told his family he didn't want heroic measures, but that is precisely what he got when he suffered cardiac arrest. After five days in the ICU, she realized her father couldn't have the life he wanted, so she belatedly arranged his death. I think we as a society are so unused to seeing what a natural death looks like that sometimes we don't recognize it when it is staring us in the face.

Those are the two extremes: the rare one of dying quietly at home and the more common one of expiring amid the impersonal clutter of ICU machinery. My residency program spends a lot of time talking about how to get comfortable helping patients and family choose either to avoid the machines or that it's okay to turn them off, all in the name of enabling them to realize their dream (and ours) that they die somewhere else. Taking care of patients who die can be emotionally and physically exhausting. If that death happens in the hospital, it is also financially expensive. There are a lot of reasons--individual and social, spiritual and selfish--for wanting deaths like Old Man Johnson's to occur at home.

But I worry that learning how to give patients opportunities, permission even, to say, "No" to invasive interventions such as dialysis, intubation, and feeding tubes biases us against the ones who do want everything done, even if we (and usually they) know they are going to die anyway. The old man who would rather bleed to death on blood thinners than risk a debilitating but not deadly stroke. The middle-aged man who wants to stay in the hospital on dialysis because it keeps him alive enough to see (and say goodbye to) his family, even if he will be discharged through the morgue. The woman who agrees to be admitted every time she is sick, because she knows her husband would not forgive himself if they agreed to the comfort measures that would shorten her life of suffering. It's not a choice if we insist they choose what we think is best.

Image credit Paul VanDerWerf
(Flickr), since I can't find my
copy of Miss Rumphius (this
YouTube version has sound
effects and rhymes)

This M&M case helped me to identify an area of discomfort in my medical practice and, by naming it, sit with it until it became a little more comfortable. It is not unlike the discomforts that feminism asks us to accommodate, in the name of agreeing that women have the right to make choices different than our own. I do believe there is such a thing as "a good death." I imagine that I want mine to occur in the distant future, quietly. I think of taking my last breath while sitting in a comfy armchair looking out on a garden of lupines on the coast of Maine. Other people have other, equally valid definitions--like Old Man Johnson, his arsenal, and his lighted cigarette.

"I don't think he's going to go quietly." In fact, it looks like he's going to go out with a BANG...at home. And somehow that needs to be okay.



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