More About The End

While on this ICU rotation I am seeing a lot of sick people and a lot of dying and it has inspired me to focus a little of my writing and reading on a personal interest of mine - Palliative Care in the Emergency Medicine setting. There are a number of articles recently that deal with issue or something near it and I wanted to consolidate a few here as well as transcribe a comment I posted on a Wall Street Journal's Health Blog article recently.

• Atul Gawande on ICU Care and Palliative Medicine (from The New Yorker)
• The new "Quality of Death" index
• Cancer patients live *longer* with Palliative Care - NEJM
• A fabulous article in Slate - We Can't Save You
• Emergency Rooms and Palliative Care
• Some basics on Palliative Care fro mWikipedia
• Sub-specialization in Palliative and Hospice Care as an Emergency Medicine MD
• Palliation in the Emergency Department setting

My recent comment on the WSJ article that became a post in itself I think:

I am an Emergency Medicine resident and currently on a medical ICU rotation (MICU). I spend my days either in the ER admitting very sick patients often at the end of their lives or in the ICU caring for these patients. I recently wrote on my blog (after a particularly difficult 32-hour shift) some of my views regarding the medical establishment's approach to patients, illness and the end of life.

To be honest, I feel that enduring the very last moments of one’s life in a busy Emergency Dept or ICU as just about the worst possible experience for a patient and family I can imagine. Just a few days ago I helped a family through the final moments as care was withdrawn from their father in the middle of the Emergency Department. He had end stage cancer, was in pain, delirium and complete organ and was admitted to the ICU for “escalation of care”.  It was not until we were at the maximum doses of three different vasopressors and a ventilator to keep him breathing did we finally, as a medical community, truly convey to the family and patient that we could only prolong death through great suffering. At this point the only thing keeping him alive were chemicals and machines.  We could keep his heart beating and lungs breathing for a little while longer but only at the expense of the family as they watched him languish. We finally told them they had another option and they decided to let him die. The sad part is that arriving at this decision so late meant he would die in our Emergency Department and not at home with them as he could have had someone truly offered these options earlier. I had plenty of pain medications and sedatives to ease this patient’s transition but that family had to endure these final moments surrounded not by peaceful silence or familiar surroundings but instead by the sights, sounds and smells of an ER. ECG alarms, vomiting, people moaning in pain, the smell of infected flesh from the gangrenous legs next door and the occasional trauma that was rolled by on a gurney with a screaming and bloody patient forcing the family to view the mangled wreckage of a body after a car accident – this was what surrounded the patient and family in those last moments of death. Despite our attempts to provide a calm environment for the family the entire episode was traumatizing for everyone I am sure.  We are an overloaded and overcrowded ER and were limited in what we could offer. 

The Emergency Department and hospital in general is designed and expected to be a place where we intervene to “save” patient’s lives and not a place where we can help them end them. We have not truly embraced a role in the relief of suffering at the end of life as equally as we do trying to prolong life, which is why we fund and train doctors in ICU’s and not in Palliative Care. Palliative Care is often seen as that last “alternative” that we only consider in extreme cases and many doctors view it as “giving up” I feel. I wish we, as a medical community, understood and agreed that medicine is not just about treatment of disease with the hopes that we can "fix" it but that it ultimately should be about the relief of suffering and the realistic understanding that death will come and we can’t always change it. What we can do though is to participate in it with the family – embrace it. At any time patients and doctors should feel comfortable choosing either path. We need to be better about identifying these patients that are at the end or rapidly nearing it and educate them and their family on the services available and present them as equally valuable options. Just as we have learned that offering wood floors and natural lighting with a calm environment in a birthing suite creates a better birthing experience for the entire family we similarly need to have a place for people to die. This means we need to offer rooms, staff and training so that we as doctors feel just as comfortable about choosing Palliative Care as we do about admitting someone to the ICU.

In the Emergency Department we have a unique opportunity to guide these patients to a different experience at the end and we should not feel that all sick patients must be admitted to the ICU. It not only makes human sense, it makes financial sense. These services, medications and facilities are much less costly than the ICU and would provide much less suffering for the family and patients overall. Palliative Care is a valid and powerful choice equally as valuable as a defibrillator and not a last ditch option viewed only after we feel we are out of choices. It is not “giving up on” a patient; it is redefining our goals for that patient. Perhaps one day we can see Palliative Care in the ER as a different type of escalation of care – an escalation in the treatment of suffering. The end will always come and it will always be painful for those close to the patient, but we can do a better job for many of these patients through more aggressive palliation and not more aggressive resuscitation.