Death and failure


I was discussing my thoughts on the book "The Spirit Catches You and You Fall Down" with a friend of mine who also read it. We were both amazed at how something so basic as caring for a sick child resulted in such tragic consequences, and it's no surprise to folks like us. We're both Asian, and we've had our own experiences with the clashes of Western medicine and Asian cultures. Neither of us are Hmong though, and it's a pretty different viewpoint.

But then my friend said something really funny to me. "It's so sad that she died, and it was all from—"

"What? Wait a minute. She doesn't die. In fact, according to the book's website, she's still alive."

"No, she died... didn't she?"

"Umm... no she didn't. She's alive."

In medicine, we equate death and failure. We can't separate them, or at least it's very hard. It's why some oncologists will wait till the very last second before sending someone to hospice. It's why we take worse care of DNR patients than full code patients. Even my previous comment is biased towards life-saving measures. Is it worse care, or is it more appropriate care?

But the truth of the matter is that in the medical field, we have a very hard time dealing with death. I have my own theories. I think when it is our own lives, they have a beginning, a middle, and an end, and although most of us are not seeking out death, we understand that it is a part of being human. And we can be content with that based on our own self-worth, which is the totality of our life's experiences.

When you're a doctor, all you see is a part of that life. You may see the beginning. You may just see the middle. But almost never do you see the whole thing. And so a doctor is not able to determine the value of a person's life based on life experiences or anything substantive. We are left with only one way to judge a life's value: quantity. We try to get people as much time as possible, with the belief that adding days will add value.

And in general, board strokes, quantity is valuable, but only to a point. For example, someone on his death bed is probably not concerned with the performance of his stock portfolio. So quantity is clearly not a definitive measure of worth, and so we as doctors are forced to rely on patients and families to tell us what a life is worth, and when it is okay to cut back on quantity, to give a little quality.

I remember one ICU patient was ready to cash out, so I talked to his son, trying to see if we could change to comfort measures. His son was conflicted. "If it was me, I'd say enough is enough. But my dad, he was real stubborn. He would never give up an inch, and I know he would want to fight to the very bitter end. What should I do?"

I could've talked him into palliation, but that's not fair, because in the end, his role isn't to play God, and neither is mine. It's simply to convey his dad's wishes. "When I talk to families, what I really want to know is what the patient would've wanted. Sounds to me like you've given me the answer. I'm gonna keep being real aggressive, and when you think he'd have hit his limit, then you let me know."

1 comment:

Liana said...

I read that book too... then realized that I'd met Dr. Dan Murphy (who is mentioned briefly in the book) in East Timor. Small world.

Your theories on death in medicine are very true.

This is my first time on your blog (found you via the comments on vitum medicinus) and I'll be back!