A recent article in the New York Times by Sandeep Jauhar, entitled “It’s not just about quality of life,” addresses a topic that is difficult to talk about: delivering aggressive medical care in the intensive care unit (ICU) for patients at the end of life. The article points out what a challenging situation this can be for both families and health care providers and how conflicts can arise when there is disagreement about what level of care is appropriate.
As a pulmonary and critical care physician, a large part of what I do involves caring for patients in the ICU. I have struggled through these types of decisions with patients and families on many occasions. In my experience, true conflicts between physicians and families are very rare, as long as there is good communication. Although the experience of having a critically ill family member is undoubtedly one of the most difficult things anyone can face, there are a few important points that can help you make sure that you or your loved ones receive the best possible care in such a circumstance.
Talk about your wishes in advance.
It is surprising how often families don’t know what level of aggressive treatments would be acceptable for their loved ones in the ICU. Although discussing these issues can be difficult or uncomfortable, making sure that you have made clear to your family what you would or would not want done in the case that you were not able to speak for yourself is one of the most important things you can do to protect your family from the stress of not knowing what you would want. In Oregon, one of the best ways to make your wishes known is to complete a Physician Order for Life Sustaining Treatment (POLST) form.
Avoid arguments about whether a treatment is futile or not.
Whether or not any medical treatment is beneficial depends on the specific situation. When counseling patients and families on the most appropriate care, I focus on trying to understand what the patient’s goals and wishes are and then I provide advice on which treatments can help achieve those goals. The reality is that there will come a time for all of us when, near the end of life, medical treatments will have no real potential to restore health and would only prolong the dying process or cause suffering.
Know the alternatives.
I cannot tell you how many times I have heard families and other physicians use the term “just do everything.” The idea is that when faced with the difficult situation of a loved one who is critically ill, we want to do everything possible to help. This is then translated into meaning that every aggressive treatment or procedure should be tried, even if there is little to no hope that they will help. This is a situation in which we as physicians need to do more to make sure that patients and families understand that it is not a matter of doing everything versus “giving up,” or worse, doing nothing. Instead, discussions should focus on the wishes and goals of the patient and providing treatments that are consistent with those wishes and goals. When it becomes clear that aggressive or invasive treatments will not be effective, we can transition to focusing on minimizing pain and maximizing comfort. Far from doing nothing, this change in the goals of care (often referred to as “comfort care” or “palliative care”) can be one of the most important treatments that we as physicians can provide to our patients at the end of life.
Brad Glavan, MD is a Pulmonary and Critical Care physician at The Oregon Clinic and cares for patients in the intensive care unit at Providence Portland Medical Center and Providence Milwaukie Medical Center.