09 June 2004

When Do We Stop?

Since I wrote my June 6 post on Alzheimer's Disease and Ronald Reagan's demise, a commenter from Spain who signs his name as "Kano," and I have been exchanging views on death, dying, and the roles doctors and relatives alike should play in such dire situations.

As doctors, we often face situations in which patients are in critical conditions, meaning the degree of survival is very minimal. This happens in many cases: traumatic accidents, cancer, AIDS, extremely septic cases, stroke, heart attack and many, many more. A typical scenario is a patient in a critically unstable (read: he can expire anytime) condition transferred to the Intensive Care Unit (ICU), unconscious or comatose, hooked to a respirator, has had about 2-3 cardiac arrests but was revived, and being given intravenous cardiac medications like dopamine and dobutamine. In my young practice, the highest mortality rates among such cases are observed among the elderly population (65 years and above). In these cases, we usually talk to the relatives of the patient, informing them of the gravity of the patient's situation, probability of survival, and of the impending costs of maintainance. Sometimes, to curb expenses, they are advised to buy their own medicines and medical supplies directly to their pharmacy of choice. Worse, sometimes, they are asked to transfer to low-cost hospitals, again of their choice.

The valid and interesting points raised by Kano in situations like these were:
"I wonder why we, under the name of compassion or humanity or whatever you care to call it, would allow our closest family members to suffer prolonged, horrible deaths -- be it this disease or cancer or some other hopeless and incurable disease.
"Why can't we let them die in peace and dignity? Is it for our own sake that we prolong their pitiful existence? No farmer would allow his carabao to suffer something like that -- it would be 'inhumane'"
"For me, the Hippocratic oath is hypocritical when used to justify prolonging what in reality is only hopeless existence. Do no harm can also be seen in the light of this conundrum --- by artificially extending a person's life that is clearly and irrevocably over, thus prolonging their physical pain and suffering and the family's mental suffering (not to mention financial), isn't that in fact, doing harm?"
"This idea of course is anathema to most people. But why? Is it hope for some miracle? Is it guilt of making that decision? Is it selfishness? Is it that it is up to God to decide the time of death? Could I make that decision? All I know is that when we treat our animals more humanely than our closest family members, something is wrong."

False hopes? Continuous healing even when every indicator says the patient is on the losing end? The reality is these situations present real challenges to doctors and other healthcare givers.

In most hospitals here, they already have the DNR or the Do-Not-Resuscitate protocol, which, properly explained to the patients' relatives, is an option not to resuscitate the patient anymore in case of cardiopulmonary arrest. Pabayaan na lang mamatay. Just let them go peacefully, give them peace and dignity, spare them from further pain and agony, and of course, spare the relatives from sinking into bankruptcy paying skyhigh hospital bills.

The real problem, sometimes, or perhaps most of the time, is both doctor and relative do not know when to stop giving care.

When we stop giving care in these cases and we let the relative sign a DNR form, are we playing GOD and depriving the patient of his right to live? Or are we being selfless and kind, because we let him die peacefully?

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