Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [75]
After the nurse left, Naomi sat next to her mother. “Please, Mom,” she said. “Please consider this. I’ll respect whatever you choose, but it’s only for a short while. Please.”
Ruth didn’t answer. As the afternoon wore on, her breathing became even more labored. In the early evening, her primary care doctor arrived. He had cared for her for more than a decade, and they had grown close. Her visits to him were never brief; she often lingered, talking to him not only about her medical problems, but about her grandchildren and her activities at her synagogue.
“Ruth, we’ve talked many times about your wishes,” her doctor said. “And I am fully on board. I know the limits you set. But what we are recommending now is only temporary. Not more than a few days at most, in all likelihood.”
A heavy silence filled the room.
“Think about it again,” he said as he left.
The nurse who had told Ruth about her father came by to say that her shift was ending. “I hope you change your mind,” she said.
Ruth’s husband had been with her at the hospital since the early morning. Naomi sent him home for dinner and a shower. She sat at the bedside, refusing to leave even to get a sandwich for supper. Around ten p.m., Ruth began to gasp for breath. Naomi pressed a button for assistance.
A young doctor quickly came in, examined Ruth, and said that her blood pressure was falling.
“You need to be intubated now,” the doctor said. “We need to get you on the ventilator.”
Ruth was sitting bolt upright in bed. “I need . . . five minutes . . . to think about it.”
“You may not have five minutes,” the doctor replied.
“I am not . . . going to be . . . pressured by you,” Ruth gasped. “I need to call my husband.”
Naomi dialed the number.
“I love you,” Ruth told her husband. “Good-bye.”
Naomi started to cry.
Drs. Sudore and Fried, in their article in the Annals of Internal Medicine in 2010, posed the following scenario: Consider a patient with lung cancer who cannot be cured but who might live for two years or more. She has prepared an advance directive specifying “no heroic measures” and “no artificial interventions to sustain life.” She then develops transient heart failure. Here, her immediate prognosis is based on her cardiac function, not on the longer-term issue of her cancer. The heart condition is treatable, but if it goes untreated, fluid will build up in the lungs, preventing enough oxygen from reaching the vital organs. To survive, the patient must be intubated and placed on a ventilator for perhaps one week. Does this qualify as a “heroic measure”? Does briefly going on a ventilator to treat a transient heart condition contradict the stated wish of “no artificial intervention”? To be sure, the expected course may be quite different from what ultimately occurs. Patients cannot anticipate every twist and turn in their condition. Perhaps the patient with lung cancer and transient heart failure will develop pneumonia and have to be kept on the ventilator for a longer period of time, or the heart failure will prove to be not temporary but a more permanent problem. Do you then discontinue the artificial life support? And if so, when? There are no definitive answers because the prognosis in such situations is unclear.
Doctors and nurses are trained to save lives—and saving a life is one of the most fulfilling acts for caregivers. Without clear instructions from the patient or surrogates not to do so, the “default option” is to do everything we can to save a patient’s life. In the SUPPORT project, specialized research nurses tried to give patients and their surrogates accurate information about a prognosis to help guide their choices about accepting or declining