In high school, I worked as a lifeguard. I still remember my first rescue—the suddenness of the event, the chill of the water over my head, and the lingering adrenaline refusing to abate after we reached the pool deck. After the event, my mind whirred on with an anxious fury. What if he had aspirated? What if his heart had stopped? What would I do next? And after that?
I used to think that if only I knew enough, I could keep everyone alive. There was always a recourse, and always a new idea. Maybe it was this idea that carried me into med school, or maybe it was just a convenient story for an interview.
However it happened, in time I ended up in a medical school lecture hall learning about the mechanisms of disease and the manifold ways we could subvert them. In my mind, I was drawing battle lines, conscious of the fight I would soon be waging against each manifestation of illness and of the high stakes of failure. By this time, I still thought of life and death as unmitigated good and evil respectively. It seemed clear to me that every day, minute, and second of life gained was a victory to be celebrated, and that each ailment deserved an automatic response. A cancer was to be eradicated, a flopping heart called out for an LVAD, and troubled lungs were to proceed naturally to a ventilator and then to ECMO.
Yet when I began to care for patients directly, my perspective rapidly began to shift. In the hospital, I witnessed the harm occasionally caused by our own interventions and witnessed sleeping bodies tortured relentlessly to eke out a few more silent days. I saw also the tranquility some found in facing death and meeting it on their own terms. Over the months in which I cared for critically ill patients, I came to realize that to “rage against the dying of the light” was a noble act only if it occurred on behalf of the patient, rather than on behalf of the medical staff. This is not to say that all drastic life-saving measures are misguided, but rather an encouragement to consider their use within the broader context of a patient’s goals.
I believe that there is such a thing as a good death, and after a long experience in the hospital, I also believe that there is such a thing as a bad one. I think most healthcare workers intuitively understand this and it is evidenced by the different ways they choose to die. When compared to the general population, more healthcare workers opt for Do Not Resuscitate orders and larger proportions choose to die at home. But why do we not achieve the same for our patients? I think this difference stems from the innate posture towards death which drove us to medicine—namely, that we were drawn to this field to save lives, not to let them slip away. This also is a residue of our culture, not just in medicine, but across the western world. It is through this cultural aversion to the topic of death that we seek to push away any discussion of the subject, and thus are unprepared to give up the fight when the appropriate time comes. In healthcare, we are forced to confront not only the topic of death but also the very real limits of our ability to hold it at bay. This gives us the advantage of long introspection about our own mortality, but within the greater cultural milieu also makes it difficult to provide the same perspective when caring for our patients.
The urge to fight is so strong that it can easily overwhelm our more considered judgment and lead us to cause more harm than good. In order to better advocate for patients, I have learned that I have to moderate my own inclinations and approach the questions of end of life care with humility and with compassion. This includes being willing to have frank and occasionally uncomfortable conversations but in the end, I believe this equates to better care and in a more holistic sense, better outcomes.
Read more on autonomy and beneficence.