A North Carolina hospital found itself in hot water earlier this month after it unveiled a new marketing slogan: “Cheat Death”. The hospital’s administration apparently didn’t realize that the catchphrase might be considered to be in poor taste, but they were quickly apprised of this fact. As an intensive care unit doctor who routinely cares for dying patients, I was alarmed for a different reason. The idea that we can cheat death belies what all of us know to be true: Everyone dies.
As an intern fresh out of medical school, I encountered a patient in the emergency department who had new abdominal pain. It turns out that she was experiencing a rupture of her aorta, the largest, most vital artery in the body. Without surgery, she would die. With surgery, she might die, might be connected to a breathing machine for the rest of her life, or might have a long, complicated recovery. With her family surrounding her, she said, “I’m 90 years old. I’ve had a good life. I’m ready to go.” This woman understood that she would die at some point, and chose to go on her own terms. While I would like to say that most patients go the way that this woman did, the reality is far from this woman’s peaceful passage in the company of friendly faces.
I’m not sure how death came to be considered failure in American medicine. It puzzles me that in a society where most people subscribe to religions that teach of a glorious, perfect hereafter, we often exhaust every possible intervention, no matter how painful, to eke out a few more moments of “life”. There are, of course, situations when we are supposed to do everything. Consider the story, widely publicized, of young a pregnant mother at our institution who contracted swine flu. She was placed in a medically-induced coma and connected to a heart-lung bypass machine. It took her months to recover, but she eventually made it home and met her infant son. The heroics employed to get her through her illness were the right thing to do, and fortunately the patient had a good outcome.
Contrast this with what I see in the intensive care unit, week in and week out. Along with the people you might consider temporarily critically ill, we always have a few people that fall into what we call chronic critical illness. Imagine being connected to a breathing machine for months at a time. Sometimes delirium sets in, because you can’t sleep right in an ICU with the alarms ringing and machines hissing 24 hours a day. When your family and friends come to visit, they have to wear special gowns because you’ve been infected with a superbug that’s resistant to antibiotics. Is this “cheating death”? Maybe the ones being cheated are the patients who are unable to live life the way they want to, or families who cannot have meaningful conversations with their ailing loved ones.
I don’t mean to suggest that anyone who has a prolonged recovery is not entitled to aggressive medical care. I also don’t think that doctors and other healthcare providers should decide alone about the appropriateness of life-sustaining therapy. But there are cases when I know full well that a given patient is not going to get better. They won’t go home and relax on the couch reading the newspaper. Some patients will never be able to get back to the golf course or the garden. More important than my knowledge though, is that these patients’ families know it too. I see it in the resigned nods that I get when I explain that things aren’t getting any better, that in fact another problem has arisen.
What baffles me is that even when everyone seems to agree that death is coming, often no one is courageous enough to let it happen. We talk about “giving up”, about “pulling the plug”. I suppose that when we talk about death in terms of taking things away, it is only natural to resist. I prefer to think about “allowing natural death”, an acknowledgement that death is indeed part of the life cycle. While this concept doesn’t make end of life discussions easier, my hope is that it helps families not think that they are killing their loved one by changing goals of care. Perhaps this is my way of moving the discussion away from ways to cheat death and toward ways of living a fulfilling and meaningful life.