The road to hell....

I met him during my ward rounds. In his 60s (looked 80, I thought), a very skinny man (wasted, I thought) who had had a lobectomy (removal of a lobe of his lung) for a cancer. He was finding it difficult to take a deep breath due to the pain, despite being on every modality of pain relief known to mankind. Therefore, he was not able to be mobilized, and was still needing oxygen. He had hardly had anything to eat in the post-operative period. 'Nearly end-stage emphysema with Right heart dysfunction and Pulmonary hypertension. Has lost 10 kg in the last year' said the pre-op anaesthetic review.

He had had the procedure a couple of days back, and due to the severe damage and scarring of his lung, he had developed a pneumothorax as a complication of the surgery. Added to this, due to the fact that he was relatively immobile, and finding it difficult to cough and clear his secretions, he had developed a chest infection. The supplemental oxygen was just sufficient to ensure safe levels of oxygen in his system, and over the course of the last 2 days, his oxygen requirements were increasing: all in all, this man was deteriorating and his outlook was looking grim.

The junior doctor asked me: "Would this patient be appropriate for intubation, in case of worsening respiratory failure?" I groaned inwardly as I asked her what would intubation and ventilation achieve in this patient? "Well, it'll keep him alive", she said, somewhat uncertainly. Suppressing an urge to shout "Staying alive (on a ventilator?) is not everything, it is the quality of life that counts!", I asked her whether anyone had discussed this with the patient and his family? Surely, he must have been seen by doctors and healthcare teams of various types?

We looked for the 'Goals of Care' form in his file, and found it there, at the very beginning: 'In the event of cardiac arrest, this patient is for resuscitation (the so-called 'Full Resus') and intubation".

I (finally) spoke to the patient and his daughter, who was by his side. 'How far are you able to walk on a good day, Sir?' He thought for a while, and answered (did I see a twinkle in his eye?): "Easily a kilometre". I mentally rolled my eyeballs; his daughter burst out laughing, and I must confess, I smiled as well. The patient did so too with a shrug that seemed to say "Well, I thought I'd give it a try". "He would be lucky to be able to walk 20 steps" said his daughter, "I was in fact surprised that they took him for surgery after all!". I was struck by the earthy common-sense on display here. "Do you know the extent of your illness? Has any doctor ever discussed death, dying and resuscitation with you?" I asked the patient (Surely, someone must have done so?). "No, no one has discussed this with me in specific terms. " I was thunderstruck: surely, we as doctors, medical specialists, ought to have afforded this gentleman and his family this minimum dignity, and courtesy, and maybe, even the relief that this topic had been brought up?

The patient went on:"I know I am very sick, and that I do not have long to live. I value my independence the most. I wanted this surgery as I wanted to get better. I did not realize things could turn out bad. If I were to become more unwell, I would not want to be kept alive on a breathing machine- in that case, please keep me comfortable, and let me die." Both his daughter and he were teary now, but relieved, and I could say nothing other than "I think you are a very brave and wise man, and I understand and respect your decision. Please let me know if there's anything else I can do for you."

I stepped away, and felt like this patient had been callously treated by the entire healthcare system, all with good intentions (What was that about the road to hell being paved with good intentions?). With frailty along with an advanced terminal illness, his chances of making a recovery to the extent he would both survive and then qualify for post-operative chemotherapy would (in my opinion) be very small. His complications and the need for a prolonged hospital stay with the inevitable decline in (his already poor) function were both eminently predictable.

Therefore, what exactly was achieved by subjecting this emaciated (can I use the word 'Dying'?) man to a major surgical procedure that had effectively bound him to a long hospital stay with a very high chance of either dying in hospital or ending up in a nursing home having lost the ability to look after himself? Was there even the semblance of an honest discussion with him prior to the surgery in this regard? Did anyone have the courage to look him in the eye and say:" I don't think you should have this procedure. You are too frail, and the chances are you won't make it. We will try and ensure you die a dignified death at home."

What has happened to Medical Leadership? Where is it hiding?

Disclaimer: The views and opinions expressed in this article are my own, and do not in any way reflect those of the organizations I work for or have worked for in the past.