Misleading Metrics

2017-10-23T22:04:23+00:00 February 21st, 2017|

A few years ago, while at a family get-together, I sat across from a retired hospice social worker named Terry. I am a physician whose practice alternates between attending on the wards of an inner-city intensive care unit and serving as a consultant on the hospital’s palliative care team.

I didn’t set out to practice this uncommon combination of medical specialties. I started out totally dedicated to using the miraculous technologies in my critical care toolbox to maximize the number of heartbeats before death. But as I increasingly found myself “rescuing” many of my seriously ill patients into a life of suffering and dependence on machines, I began to question that paradigm. I went on to learn the practice of palliative care medicine, with its focus on providing care aligned with patients’ stated values. So my ears perked up when Terry began to speak of her fear of a bad death. Then she told me a chilling story.

A year earlier, Terry had been thinking a lot about death. Although still spry at 80, she had no close family living nearby and worried that if she were no longer able to speak for herself, she might be “hijacked,” as she put it, into a bad death. She was no stranger to the overuse of technology in dying patients. There was no doubt in her mind that she would never want to be kept alive on machines if she didn’t have a chance of getting back to her life as a fully functioning individual. She had documented her preference on an advance directive, checking the box that stated:

I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits.

Then she had informed all of her close friends of this decision. But the best-laid schemes often go askew. It wasn’t long after she filled out her form that she was taken to the hospital with crushing chest pain. She had mentally rehearsed this moment, and maintained the presence of mind to bring her advance directive to the hospital. But when she handed it to the cardiologist in the emergency room and said clearly, “I don’t want to be placed on any machines at any point,” he looked at her as if she were crazy. (…) Read Full Article Here

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