As cautiously as I can, I tell them that when they’re ready – as anyone really can be for all this – we will stop the drugs and the tubes that prolong life. I tell them that the nurse at the bedside will give other drugs, often morphine or a similar drug, to make sure their loved one is not in pain. Sometimes they ask if this drug will hasten death, and I explain it can, but our primary goal is always to relieve discomfort.
We even have a term for this balance, the “dual effect principle” – as physicians we accept the risk of a negative consequence such as hastening death, as long as our intended outcome is to help the patient by alleviating symptoms. The pain-relieving drugs we administer do not themselves cause death; instead, they make sure that our patients feel as comfortable as possible while dying from their underlying disease.
Some relatives ask us to stop everything at once. Others call for a longer process, to stop one drug and then another. Recently someone asked the nurse to run out of all the medicines and not to replace the IV bags. Some ask us to remove the breathing tube, others don’t. I am often amazed at the extent to which people have ideas about what feels right to them, about how the unimaginable should turn out. Sometimes there is music. Jerry Garcia. Beethoven. For others, this is all one decision too many, and they sit in silence.
A resident doctor in training came to me recently after one such family gathering, fearing that he had made it happen by telling a family that their loved one was dying. If we define death solely by physiology, by falling blood pressure or oxygen levels, then perhaps that concern is justified. But when we broaden our definition, when we think of dying in intensive care as something that begins when an acceptable outcome is no longer possible, we recognize the inevitable.
That’s what I told my patient’s wife outside his room that day. We had given her husband every chance to recover, to show us that he would make it, but the insults his body faced were too great. We can go on, but for what purpose? He would never come home, never be able to do the things that made his life worth living.
She was right, the timing of this conversation was random in a sense. If I had been dealing with a patient in extremis, I might not have stopped her outside the room that day. But once we recognized the reality of her husband’s medical condition, what choice was there?