Feb 11, 2023·edited Feb 11, 2023Liked by Meredith Yang
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.
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.
We need to learn about death. We need to understand our illnesses and treatments and what is possible. We need to understand when to ask for palliative care and when hospice is needed because if we are afraid to learn about illness and death we will be 99 and doctors will be pounding on our chests and those will be our last moments.
For some reason I have been the accidental death doula in my family. I have been lucky. I held my grandmother’s hand and my mother’s hand and my best friend’s hand as they died. As hard and traumatic as that was and yes it was traumatic it was a sacred time to be with them.
The world is lucky that you are going to be a doctor.
This essay released a wave of emotion remembering the death of my mother 30 years ago. The things that become meaningful when a loved one dies.
-telling the nurse to put my mother’s dentures back in after they pull the ventilator tube out
-picking a casket just because it has small flowers on the handles
- getting a new dress for her. (I think back and wonder what the sales lady thought when this new widower came in with his 4 sons looking for a dress for his wife’s funeral).
And any number of other things my fat hate and brothers felt had meaning that I don’t remember.
My grandmother was dead, and so everything mattered
That’s what got me. And made this cynical middle aged man a mess during his morning coffee. But I think I can forgive you.
You have found your Super Power and I think each person you work with will be the better for it.
This is a lovely essay. I regret sending my husband to the hospital when he was dying, I wish I had let him go more peacefully. But we must always have hope.
Nicely said and was a reminder of similar situations I remember vividly from my early training that were sad, emotional and yet touching. It made me realize that the humanity of medicine will always be the most important thing we do. We can give the best care and try so hard to make a difference(which at times we do) but being a human and letting the patients know we care. Keep writing you can tell stories that need to be told and read.
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.
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.
Thank you Meredith Yang.
We need to learn about death. We need to understand our illnesses and treatments and what is possible. We need to understand when to ask for palliative care and when hospice is needed because if we are afraid to learn about illness and death we will be 99 and doctors will be pounding on our chests and those will be our last moments.
For some reason I have been the accidental death doula in my family. I have been lucky. I held my grandmother’s hand and my mother’s hand and my best friend’s hand as they died. As hard and traumatic as that was and yes it was traumatic it was a sacred time to be with them.
The world is lucky that you are going to be a doctor.
Thank you for sharing this with us.
This essay released a wave of emotion remembering the death of my mother 30 years ago. The things that become meaningful when a loved one dies.
-telling the nurse to put my mother’s dentures back in after they pull the ventilator tube out
-picking a casket just because it has small flowers on the handles
- getting a new dress for her. (I think back and wonder what the sales lady thought when this new widower came in with his 4 sons looking for a dress for his wife’s funeral).
And any number of other things my fat hate and brothers felt had meaning that I don’t remember.
My grandmother was dead, and so everything mattered
That’s what got me. And made this cynical middle aged man a mess during his morning coffee. But I think I can forgive you.
You have found your Super Power and I think each person you work with will be the better for it.
Thank you for sharing.
That was suppose to read father not fat hate. Can get to edit my comment
This is a lovely essay. I regret sending my husband to the hospital when he was dying, I wish I had let him go more peacefully. But we must always have hope.
Nicely said and was a reminder of similar situations I remember vividly from my early training that were sad, emotional and yet touching. It made me realize that the humanity of medicine will always be the most important thing we do. We can give the best care and try so hard to make a difference(which at times we do) but being a human and letting the patients know we care. Keep writing you can tell stories that need to be told and read.