So Long, and Thanks for All the Treatment

 

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One thing the pandemic, which seems to be here to stay, has taught us is that one should be well aware that life is finite. We all know this, of course, but we would rather not think about it, thank you very much. Then, all of a sudden, an unforeseen threat pops around the corner, our cozy hospital environment becomes a virus spreader, friends get hospitalized and do not fully recover—or even die. Cardiac surgeons roll in their life-saving equipment and start playing an important role in the treatment of this icky infectious disease they would rather see the back of. They get their vaccinations and feel safer, but when, after their last efforts on the medical intensive care unit (ICU), throats begin to feel sore and noses start running, they are not so self-certain and cool anymore. Now what?

In this gloomy context, it is rather interesting to learn that physicians normally show a tendency not to die in a hospital's ICU.[1] [2] A possible, and in my opinion highly likely, explanation reads like this: “However, the lower rates of hospital deaths of physicians … suggest that … actual experience with hospital deaths may differentially motivate physicians to avoid them.”[1]

Another analysis investigated the willingness of severely ill patients to trade in absolute life time for a more comfortable death at home.[3] This was a prospective cohort study in participants “60 years and older with serious oncologic, cardiac, and pulmonary illnesses who were hospitalized.” They were presented with a somewhat macabre theoretical choice—in short: “Which future would you choose? A - Live for five years more, die in the ICU. B - Live for four years more, die at home.” Again, “of 180 patients presented with the survival time tradeoff question, 156 patients (86.7%) said they would trade a full year of time alive to avoid the scenario in which they were in the ICU for 3 weeks at the end of life and died on life support.”[3]

You may argue that a metastasized ovarian cancer is not the same as a Covid19-induced pneumonia, but still many people seem to harbor serious doubts or even distrust about a medical overkill toward the end of their life, doctors apparently included foremost. Most of you would probably consent to a limited ECMO run to temporarily improve oxygenation. But what if multiorgan failure had already set in with only a very small chance of recovery? What if hypoxia had already caused brain damage clearly visible on repeated magnetic resonance imagings? Full steam ahead? Do your next of kin know about your attitude when you cannot be asked anymore? Are they entitled to make difficult final decisions on your behalf? Do they possess an authorized advance directive? We are dealing with these uncomfortable questions and situations in our daily professional life treating others. But it could be us any time.

A fashionable if slightly unconventional way for an advance directive in this age of body art is a “Do NOT Resuscitate” tattoo on the chest.[4] Although seemingly unequivocal at literally first sight, it may still cause considerable discussion among the medical professionals confronted with it.[5] [6] [7] [8] End-of-life decisions are the most difficult ones we have to make, especially when they involve withdrawal or withholding of treatment. I doubt if we as cardiac surgeons give this problem enough thought, let alone are adequately trained to handle it. There is no better way to sum up this dilemma than Atul Gawande did in an Editorial for an issue of the New England Journal of Medicine in 2016, “dedicated to the topic of death, dying, and the end of life,” a volume that makes fascinating reading.[9] His last words (please excuse the pun) were: “Everyone dies. Death is not an inherent failure. Neglect, however, is.”[9]

Publication History

Article published online:
21 September 2021

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• References

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