A recent opinion piece in the New York Times caught my attention: “Who Are We Caring for in the I.C.U.?” I thought it would just be another exasperating chronicle of the staggering disproportion of unvaccinated people needing intensive care compared to the vaccinated. But I was wrong.
Dr. Daniela Lamas is a pulmonary and critical care specialist. In the article, she addressed a topic that often arises in the care of critically ill patients: what is a physician to do when the family of a loved one wants interventions that are clearly useless in a terminally ill patient who is unable to make his/her own decisions?
Dr. Lamas tells the story of a family’s request to transfer a Covid-infected patient with respiratory failure to her institution, a larger hospital with greater resources than the transferring hospital. Talking to the ICU doctor at the other institution, she felt that her hospital could do nothing that the other hospital had not already done. Moreover, the transfer itself could be dangerous.
Nevertheless, she OK’ed the transfer. Why? First, let me tell you of a wise observation one of my esteemed medical mentors told me years ago: the care of the demented patient is largely the care of the patient’s loved ones. This acknowledges the paucity of effective therapies for patients with end stage dementia, at the same time understanding the needs of family members. They need to know that all reasonable interventions are being undertaken for loved ones, that the patient will be kept comfortable, and that mortal decisions are understandably excruciating. Sometimes, misplaced guilt needs to be alleviated. .
So Dr. Lamas’ action implicitly acknowledged the needs of the members of the family–they needed to know that they had done everything possible for their loved one. Her decision was one that benefitted the family, but did not hurt the patient (the patient died two days after the transfer). Her approach went beyond the mere X’s and O’s of medical care.
Families’ desires frequently are at odds with what a physician thinks is appropriate for a patient. In the absence of a patient being able to make decisions (and in the absence of an explicit advance directive), some families want every measure taken that preserves life–every second of life is precious regardless of any other consideration.
Many times, I have been in a situation where family desires conflict with my own sense of doing what is best for a dying patient. Life is precious, but in desperate situations, my priorities were ensuring comfort and dignity.
I have never come to peace in such fraught situations. Physicians are taught, number one, to be the patient’s advocate, and doing CPR on an imminently terminal, hopelessly ill patient does not seem to be in the patient’s best interest.
With Dr. Lamas’ thoughtful commentary, however, sheds light on the less than obvious challenges in making good decisions in the care of terminally ill patients.