The Anti-Paternalists

Sometimes the way we describe surgical options to patients and their families sounds something like this:

"You have a fatal disease/debilitating illness/minor ailment that has brought you to the edge of this cliff. If you jump off the cliff/have surgery there is a 99.9% chance that you will be dashed on the rocks, there is a 0.1% chance that you could die a horrible death in the ICU with tubes coming out of every orifice and then some, and a 0.001% chance of making it out of the hospital. If you don't jump, there's a chance you could live for days/months/years but there is no chance of cure."

The fact that this is the conversation we have so often with patients and they choose to jump off the cliff for some reason that is unfathomable to me leads me to conclude that what they hear is this:

"You are sick BLAH BLAH MEDICAL WORDS BLAH BLAH and if you let me do this you may be okay BLAH BLAH but probably not."

Some of these people are very educated and intelligent, others are more simple. But I would argue that regardless of their education, we do not give our patients the tools to understand the decisions they make.  We actually make things more difficult for them by offering them a choice we know that no physician would willingly make with a full set of medical knowledge as a tool. Occasionally we are relieved when patients or their families seem to come to their senses, but to those making the decision, the price is great anguish and guilt. "Did I kill Grandma? Should I have put the feeding tube back in even though she is demented, bedridden, incontinent, and has pneumonia with bacteremia?" Even when the decision is not so elective, we are incapable of making a decision not to operate on someone we cannot conceivably help.

Why is it so unacceptable to tell our patients what treatment is within the realm of possibility? Why must we offer them unreasonable treatments that we know will cause them either prolonged or premature suffering?

My Aunt Mary was diagnosed with cancer when she was maybe 40. At the end of her short illness, she was suffering horribly and apparently insisted on a final surgery. Everyone knew that this surgery could not and would not help her, as the cancer had spread all over her body. But she begged for it, and her surgeon caved in. She survived the surgery, but it weakened her and she died shortly after.

I absolutely abhor being a Kevorkian. So many times in my short surgical career thus far I have been forced to make that cut, knowing that death was on it's way, and after the stress of surgery the elderly body will be unable to adapt. A hasty demise is all too often inevitable.

As a resident, I tag along behind poor decisions and even poorer advisements. Perhaps it is the time constraints, or the awkwardness of an honest conversation, or simply a desire to do something active in a situation where anything else is equally futile. But when the advice is my own to give, I hope that I will have the moral strength to do nothing when that is the best I can offer, and the wisdom to discern when that is the case.