Sunday, December 30, 2012

'Twas the Day Before Christmas...

...and all through the hospital there were patients and families struggling with advanced illness despite the season. (Am I the only person who takes offense when hospital units are strung with wreaths and blinking lights, and orderlies wear Santa hats? Holiday cheer at the nurses' station seems a jarring, and potentially painful, contrast to what is happening inside patients' rooms.) We met with three patients and their families on Christmas Eve day, each with its own flavor, rhythm, and backstory.

Pedro was only in his early 40s, dying of advanced liver disease. When the liver goes, often the kidneys quit, too. We call that "hepatorenal syndrome," and dialysis -- what you'd normally think of when kidney fail -- is ineffective in this circumstance. The liver and kidney experts were tinkering around the edges, giving drugs and fluids in various combinations. But the blood tests were getting worse every day.

When I sat down with Pedro, I told him there was at best a 50-50 chance he'd live for another three months. He told me that he wasn't ready to die. His father had died two years ago -- ironically from kidney failure -- and Pedro and his two brothers were worried about their mom, who was clearly beside herself with grief. I explained why dialysis wouldn't help, why the medications weren't working, and that time was very, very short. We talked about his "code status" -- would he want us to attempt to bring him back if his heart stopped? -- and he was clear that the answer was yes. He did follow our advice and signed a form naming his brother Juan as his medical power of attorney.

Next door to Pablo was Bernie, a fellow in his late 60s who'd lost his independence as multiple episodes of pneumonia sapped his strength. Those, in turn, were probably caused by his difficulty with swallowing leading to aspiration. And all of that was set on the background of longstanding lung disease from a lifetime of smoking. Bernie had already made clear to me that he wanted nothing to do with resuscitation attempts. So our family meeting -- which included his sister and his ex-wife, with whom he'd maintained a cordial relationship -- focused on what was achievable and what the road ahead might look like. Bernie desperately wanted to return home, even if he would have to accept some help there. We talked about the possibility of that happening and how it would be hard to avoid at least a short-term nursing home stay with some rehab. His sister asked me to estimate how likely it would be for Bernie to get what he wanted, and I had to tell her he was facing long odds.

From there we moved on to the ICU to meet with Paula and her family. Paula couldn't participate in our discussions. A woman in her early 70s, she'd had metastatic breast cancer diagnosed a year before. Nothing worked, and she was in the ICU on a ventilator and sedation because she'd had overwhelming sepsis and two cardiac arrests in which the doctors and nurses were able to get her heart started again. "That's what's on her advance directive," one of them told me. The form she'd completed had two choices -- essentially, "let me go" and "keep me going even if I have to spend years on machines" -- and there was writing alongside the second choice.  I took a closer look. She'd placed her initials in the margin next to the "do everything" choice and written "NO" in capital letters in the space where her initials were supposed to be. She'd filled the form out backwards, or so it seemed. Her husband, sons, and daughter all confirmed that "this has gone on too long" and "she never wanted this." They were worried about her struggling for air if she came off the ventilator, so I walked them through our process for assuring that patients don't gasp or feel like they are choking. They seemed relieved but asked for more time to think things over.

So how did things turn out for my three Christmas Eve day patients? Christmas was on a Tuesday this year. By Friday Pedro had told everyone that he was at peace with dying. He agreed to permit a natural death and, trying to comfort his mother at the same time, moved to the inpatient hospice unit. Bernie was discharged from the hospital that same Friday to a nursing home, telling us he never wanted to come back to the hospital, that he knew that time was short, and that he realized he might never get home. And all of Paula's out-of-town relatives had arrived by Thursday evening. They said their good-byes, the ventilator was discontinued, and ten minutes later she was gone.

So three families struggled with hard choices on the day before Christmas, and ultimately each made the decision that was right for them. They faced reality. But the day before Christmas had a surreal touch, too, or so it seemed to me. A local funeral home placed this advertisement in the December 24th newspaper. I quote it exactly below with the original capitalizations and punctuations -- and no, I am not making this up:

Now through December 31, 2012, receive a free metal Casket with burial pre-arrangements or a Free Urn with cremation pre-arrangements. Happy Holidays!

I hope my readers' holidays were happy even without those free gifts, and may 2013 be filled with joy and peace for you and for all who suffer, no matter what the cause.

Tuesday, December 11, 2012


You know it's going to be a tough palliative care consultation if they wait until the day the patient is discharged before they call you, or if the patient is already crying when you walk in the door. With Serena, both were true. "She's being discharged to rehab today," the referring doctor told me, "but she seems reluctant to go. Can you talk with her about her goals and what she really wants?"

You might wonder why other doctors feel they need a specialist in palliative care to find out what their patients are hoping for, but such is the nature of modern medicine. Serena's first words, spoken through tears after I introduced myself, were, "Why are they sending me to rehab? I just want to die." That's the signal for many physicians to run for the exits. The experienced palliative care doc pulls a chair up close to the bed, leans forward, and asks something like, "What should I know about you to be sure you get the best care possible?" That's what I did. And so Serena told me her story:

A professional woman in her mid-sixties, she'd contracted a form of hepatitis over 20 years before. The virus had destroyed her liver. We have no good treatments for this problem, only delaying tactics, and Serena had run out of delays. Her liver disease was end-stage; she was jaundiced with a swollen belly and no energy; and she was likely to die in a few months. Her only hope was a liver transplant, but she had studied the procedure and decided that the risks weren't worth the benefits. "My liver doctor tells me to keep on getting treated," she said. "He tells me that I could see Paris. Well, I've already been to Paris four times. I'm miserable, and I don't see the point of going on."

Some patients hope they'll run into Dr. Kevorkian when they hear palliative care is coming to see them. It's my ethical responsibility to disappoint them that, no, I won't give them a shot to make them sleep forever and to tell them that, no, physician-assisted suicide is not legal in our state. I commiserated with Serena about the rehab plan. I agreed that it would probably not help and that she'd be in a nursing home soon. (She'd long passed the point where she could care for herself at home.) "But you do have an option that would get you what you seem to be hoping for," I told her. "You could simply decide to stop eating and drinking."

It turns out that death follows within a week or two after a patient elects to refuse anything to eat or drink. You'd think it's horrible, but it's not. People who've gone without eating for long periods -- hunger strikers, those on religiously motivated fasts -- say that their sense of hunger disappears after a couple of days. And the sense of thirst arises from the mouth, so keeping the mouth moist with an occasional ice chip or one of the commercial products developed for dry mouth means that the patient won't feel thirsty.

"You can make this choice anytime you like," I told her. "I can create a safe space for you in the hospital to die peacefully if you make that decision. All of our usual medications to treat pain and other symptoms will be available. And if you suddenly decide that this is a crazy idea and that what you really want is a burger and a milkshake, we'll call room service immediately." I gave Serena my card and told her that I would help her if she ever decided to call.

About a month later, she did just that. I made arrangements to bring her to my hospital, where she enrolled in hospice under the diagnosis of end-stage liver disease. I told the nurses the plan, and they told me they were in complete agreement. With that, Serena began her voluntary refusal of food and fluids.

Over the first two days, she had panicky episodes and wondered out loud if she was doing the right thing. I reminded her that the choice was completely hers, and that I could get her a glass of water in ten seconds and a tray of food in less than half an hour. She asked for and received medication for anxiety. On the third day, she requested water and a sandwich, which we provided immediately. She took a few sips and a couple of bites. Her two remaining family members arrived from out of town that same day. They all talked privately, and Serena told me that she really was done. Her relatives agreed. She declined any more food or fluids. Within 24 hours she was unarousable. Her face was relaxed, her forehead smooth, and she was breathing easily. She died two or three days later, never regaining consciousness and never showing any signs of distress. Her family thanked my staff and me for the excellent care we had provided.

When I tell this story to other doctors, some of them recoil in horror. But I think we did right by Serena. Whether you call it VSED (voluntarily stopping eating and drinking) or VRFF (voluntary refusal of food and fluids), this is a humane and painless way for a patient to take control and relieve intolerable suffering. All you have to do is say no.