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Dr. K's avatar

As a hematologist I have been through more of this than I can measure. As I have told many patients, there is no way to make death anything other than sad for those left behind. That makes it no less avoidable, sadly.

But missing from this touching story is the cost/benefit for the guaranteed-to-fail attempt at resuscitating a 99 y/o patient with fixed/dilated pupils. I remember as a fourth year medical student having a mid-90s patient come into the ER in the same condition. I could just imagine what would happen if this brain-dead patient were resuscitated, so I assumed we would let her be in peace. No, even though she was dead, the family wanted "everything done". This would have been fine if we were God and could fix her, but at least I knew we could not. Sadly, as opposed to your case, her heart started beating again and she spent 90 days in the hospital in a coma too unstable to transfer. She ended up dying of a fecal impaction -- only patient of my long career that did so. It was horrible for everyone and cost in what in today's dollars would be the millions. I am sure your resuscitation cost at least $50K -- and likely twice that.

If money did not matter, then we could all ignore it all, but it does matter. Something between a third and a half of total lifetime health expenditures are in the last three to six months of life. (Just depends which study you like, but those are the broad parameters.) Many of those cases are just like your 99 year-old patient. Those funds, amounting to hundreds of billions of dollars are by definition not available to those who might have decades left to live, not available for research into all kinds of medical progress, and not available for the many other possible uses of such massive amounts of money.

I well understand the self-protective effect of saying "I have to do something" and "it must have made a difference" -- but much of it does not and (as you eloquently express) we know it as we do it -- or at least as well as we know anything in medicine. (This is so similar to mandating masks [known not to work for respiratory viruses] in the hope that they will do something, KNOWING they do not. But that is a topic for a different exposition.)

Death is a sad part of the circle of life and a particular, omnipresent weight on those in the healing professions. I am a strong supporter in doing what makes sense to do for patients approaching the end in both therapeutics and comfort care -- and absolutely opposed to the current Canadian trend to push those patients to assisted suicide. But as a profession we need to get a grip on what REALLY makes sense and how best to manage this with families and individuals. (The families are usually far more difficult than the individuals -- kudos to your grandma.) It cannot be "do everything at any cost" so we end up with 90 day comas at the expense of everyone else.

I wish I had all of the magic answers. But a lifetime of practicing has taught me that if we are going to have Sensible Medicine, we need to develop a more sensible approach to the peri-death experience.

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Mary S. LaMoreaux's avatar

One way is learning how to use Palliative care doctors more effectively. Hospitals need to bring these doctors in much sooner because families do not understand how the machines keep the patient alive even though their body wants to pass on.

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