June 23, 2010 Leave a comment
One of my attendings once said that there should be a sign in front of the medical intensive care unit which states, “If you aren’t dying yet, please come in: we will help you get there.” Sad but true. Welcome to a place where drug-resistant bugs fester, where depression is rampant, and where invasive and often risky procedures are done before anyone even has a chance to blink. In America, the medical system is designed to make people live as long as possible – and both the cost to society and the cost to the patients themselves are not considerations. We keep people alive no matter what the costs, or the potential benefits, but we fail to ask why we are doing it. The concept of “quality of life” is a subjective one, and physicians steer away from it and instead focus on concrete, medical interventions that will have very clear outcomes. The problem is that, in order to paint a true picture for these patients and their families, the concept of “quality of life” needs to be addressed. I would argue that it must be addressed if we are going to give a patient the most accurate overall prognosis. But we are afraid – afraid to mention the dying process, let alone embrace it. Afraid to admit that we may have failed in our primary duty as physicians – to save lives. This fear prevents us from helping our patients and families in their time of greatest need. It prevents us from giving to them what they need. I would argue that at this point, their care becomes, in part, a response to what we need as physicians. When somebody is critically ill, everyone has their bias. Physicians have the bias of seeing many treatments fail and many patients die; on the other side, we have the bias of wanting to do everything that is medically possible to save someone. Families have the bias of wanting to save their loved one – a bias which often overrules everything else. But these biases, from either side, make it impossible to paint the picture objectively. Decisions are made based on the interaction between two forces; our biases and their biases. There is no easy answer.