24 May 2012

The difficult conversation

A patient I examined had an unexpected, rapidly-progressive, and unquestionably-fatal disease that gave her perhaps weeks to live. A number of opportunistic diseases were ravaging her body because her immune system was compromised by her treatment. The patient was weak and in great distress. Her medical problems were extensive and complex.

For whatever reason, the patient and her family had tried to avoid the gravity of the situation. The patient had not crafted an advanced directive. Although home help, assisted-mobility devices, hospice care, and psychotherapy would all have been helpful and appropriate, either they hadn't been offered or the patient had not taken advantage of them. The emotional strain and the difficulty of caring for someone so ill had taken a toll on the family. What were the goals of care for these last few weeks of this patient's life? I didn't know, and neither did the patient or the patient's family. The result was a rudderless ship whose addled crew was adrift at sea.

A difficult conversation needed to have taken place. A doctor needed to sit down with the patient and ask: do you want to be fed artificially, even if this will substantially prolong your pain and suffering? Will you sign on to hospice care, so that you can relieve some of the burden on your family? What do you hope to accomplish during these last precious days on earth, and how can we best assist you with those goals?

I decided that it was inappropriate for me to be the one to have that conversation. I was only an observer, and I knew little about the patient's history, disease, and prognosis. And yet, I joined the ranks of all the other medical providers that this patient had seen, each of them hoping that someone else would someday perform that delicate, sorrowful, yet necessary task of plotting the future with one whose days are numbered.