Going the Distance in Patient Care: Should There Be a Limit?

Today marks the middle of a long stretch of night shifts in the emergency department. I have done a myriad of things – spent over twenty minutes trying to convince a patient to take a pill that she needed to treat her psychosis, sutured a facial laceration for a young gentleman who kept insisting that he wanted to leave AMA (against medical advice) and just place a band-aid on it, called a stroke code, and intubated a young gentleman who was very sick. The list goes on.

This brings me to the question: how much we should try to help patients who do not want our help? EMTs and other first responders often drive by in their ambulances and pick up patients they know well if they are lying on a park bench and are “less responsive” than usual. And their intentions, just like ours, are good – to save lives and to care for our brethren.

But patients have their own perspectives on this. I recently met a woman in her 90s who made a purposeful decision not to tell her physician or family that she had bloody stools for several months – she had lost so many people, friends and relatives, and had lived through so many decades, that she had decided she was ready to die. I met another gentleman who had lost his wife several months ago, after being married for over 60 years, whose primary diagnosis was a broken heart and a lack of will to live.

The older patients are, the easier it is for physicians to understand these death wishes. The younger they are, the more difficult it becomes. Children and young adults are always resuscitated longer than the guidelines dictate, as compared to older adults. There is a prevailing belief among physicians that age justifies death, at least to some extent. The young should not die, and the old – they shouldn’t either – but if they do, it isn’t quite as heart-wrenching.

I still remember the first night a baby died on the labor and delivery floor. I had seen older patients die in the hospital – in the emergency room and on the internal medicine floor. But the death of the baby was unlike anything I had ever witnessed. Everybody – technicians, nurses, residents, and attendings – passed the entire evening in silence. They wept behind closed doors and remained solemn, as if it were their duty, until fresh morning faces came in to replace them. I also remember the first deaths I experienced on the pediatric floors – the tears, the overwhelming grief. It is only during these moments of great, unexpected loss that time stands still in the hospital.

This brings me back to the question: how much should we try to help our patients, even if they are refusing our help? Physicians are inclined to go the distance with every patient, especially the young ones. But should we be the judge of their wishes? If someone who wishes to die is not considered a “competent” decision maker by the very nature of that wish, should we consider re-examining our definition of the term competent? And if their wishes are less dramatic – they simply do not want to take their medications or get a facial laceration sutured – how much time, effort, and energy should we spend trying to convince them otherwise?

Sometimes physicians insist upon giving care to these patients, partly because they want to help, and partly because they believe so strongly in medicine that they cannot let themselves – or their patients – stray from what they regard as the “best” care.

Yesterday evening, I gave these patients my entire effort – I spent the better part of half an hour convincing this woman to take her medication, and I spent the better part of another half hour trying to calm down the gentleman whose face I was suturing. Will they benefit? Possibly. But I will never know – this is one of the ongoing frustrations of providing care in the emergency department.