I stood at the foot of the bed and watched as the man did- nothing. His eyes were closed but I did not think he was sleeping. Sleep is what people do to regenerate themselves after times of wakefulness and he was never awake. He had no intentional control over his bodily functions, even the most basic. A machine at his bedside was responsible for pushing air in and out of his lungs. He did not even need to open his mouth to receive air, it was supplied through a plastic tube connected to a hole in his neck. He did not eat. Nutrition was supplied via another plastic tube inserted through another hole in his abdomen. His "existence" was a totally passive one.
The only times when he was not passive were when he was unsedated enough to tug at his tubes or paw at their insertion sites. There was no way of knowing if there was any thoughtful intent to these movements, whether they were a mindlessly reflexive clawing at a perceived skin stimulus or a semi-conscious expression of discomfort and a desperate desire for the suffering to end. Either way it was a heartbreaking scene. As pitiful as his movements were they did not seem to illicit compassion from his caregivers, for their response to these movements was to employ someone to sit at his bedside and attentively wait to pull his hand away from his tubes to ensure that his “life” would continue.
I stood at the foot of his bed and wondered how a man’s life could be reduced to this, how a man so young could be expected to endure so much. He was younger than me, at an age when other men would be walking their daughters down aisles or bouncing their first grandchild on their knees. He had done neither nor would he ever. His brain damage was permanent. He would never speak, communicate or walk again. His shrunken 90 pound body would never leave a bed. His tragic state would never improve. His life was as "good" as it was going to get.
I wondered, "Why are so many working so hard to extend a life no one would want?"
I have had hundreds of conversations with people over the years about how and in what circumstances they would want to be kept alive and how and when they would want to be allowed to die if their were so incapacitated. I have never met anyone who said they would want to live in a state such as his. The ability to communicate and the ability to recognize loved ones have been the universally expressed minimum functional requirements for wanting one's life prolonged. Some people say they would need to be able to do more, to care for themselves, feed themselves and have some independence, but no one with whom I have spoken has said they would want to live with less. No one would want to live like this man.
No one would want to live like this and yet people were fighting to keep him alive. They fought not just with breathing machines and feeding tubes but with antibiotics, surgical procedures and medicines to maintain blood pressure and heart function. As I looked upon his misery the question, “Why?” seemed as if it was his silent scream. Why would doctors work so hard to keep a man alive in such a miserable state?
If asked, the doctors would reply that they had no choice, that it is “what the family wanted.” In this case, and the many others like it in which I have been asked to provide ethical guidance, this is the common physician response. My frequent reply is, “What right does a family have to demand an existence that no one, including themselves, would ever want?”
Physicians forget that in cases such as this families do not have “rights” as we typically define them. Family members and surrogate decision makers have responsibilities, not rights. It is the patient who has rights, including the right to not suffer, the right to undergo only those treatments which provide benefit, the right to not have life needlessly prolonged, and the right to die with dignity. If there is a “right” held by the family it is the right to the information needed to aide them in their obligation to make sure that the patient’s rights are recognized, honored and protected. Somewhere along the way this understanding has been lost, and family wishes have been prioritized over the wishes of patients. Patients have become victims of the whims and fears of others, stripped of basic human rights and dignity.
It does not have to be this way. If physicians and hospitals can muster the courage, if they can find within themselves a commitment to doing right by their patients, this needless suffering can end. Physicians are all aware of the common tendency of family members to speak for themselves and not for the person who is dying. Knowing what we know about the dying process it is time for physicians to stop the practice of unquestionably following directives of family members that serve only to prolong suffering . The odds against someone choosing to live in a non-communicative, near vegetative state are astronomically high. Caring physicians have a duty to question the veracity of claims that such a life is desirable.
In my experience it is far more likely that family demands to prolong the dying process are based on secondary gain rather than a belief that a patient would want to live in such a state. I have never met a patient who wanted to live as the patient described above, but I have seen a number of cases where a patient's death would have an adverse impact on the financial situation of their decision maker (loss of pension or social security checks, or loss of right to live in family home). I have seen many more cases where unresolved guilt has prevented family members from accepting the reality of death and letting go. Since secondary gain for family members is for more likely in these circumstances than a patient wishing to be kept alive, one would think that physicians would want to make sure of patient wishes before yielding to unreasonable demands. This is not yet the case. Family demands almost always win out.
It might seem inconceivable that doctors would so easily allow suffering to continue, but there is a twisted logic to their response. The unreasonable demands to "do everything" are made by people who are able to speak and express anger and who frequently combine their demands with threats of legal action. Angry families are in a position to make life miserable for any physician who dares to question them. The victim of their demands is unable to speak, unable to express anger, and unable to communicate the pain they feel. They are helpless and often hopeless. The easiest path for a doctor is to give in and go along.
It does not have to be this way. Their are things patients and physicians can do to change the status quo. Patients who take the time to make their wishes known in advance and who write them in clear and detailed fashion, provide their doctors with a powerful weapon against needless suffering. Physicians who educate themselves in ethical principles and in end of life care and draw strength and courage from their knowledge. Hospitals and medical staffs can build robust Ethics Committees that are knowledgeable and responsive to requests for assistance. In the hospital in which I work we have seen this make a difference. Our Ethics team responds within hours to consult requests, answering questions and assisting doctors in responding to unreasonable demands that serve only to prolong suffering. Our Medical Staff has a policy that clearly defines when care is no longer beneficial and provides a way to free patients from harmful care.
We are seeing change. The sleeping giant of physician advocacy on behalf of their patients is beginning to wake. Needless suffering is on the decline. The change is coming slowly, but it is coming. I am grateful to be a part of it.
- Bart