Writing for the New York Times, Daniela Lamas, a pulmonary and critical-care physician at Brigham and Women's Hospital, explains how doctors and loved ones "navigate death" in cases where "it becomes clear that the life that we can offer is not one that would be acceptable to the patient."
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Making the decision to 'transition to comfort'
Many people believe that ICU doctors can easily determine whether a patient is going to die, but that's not always true. "Our medicines and machines extend the lives of patients who would otherwise have died," Lamas notes.
When a patient is fully relying on these measures—and it has become clear that they are not actively dying but are not improving either—doctors and family members must figure out how to "navigate death when it is not imminent and unavoidable but is instead a decision."
During Lamas' medical training, death unfolded in one of two ways: either in a moment of crisis, with doctors rushing into the room, trying to save a patient's life, or in a quiet room, with loved ones gathered for the patient's final breaths.
However, Lamas contends that there is a third form of death "when it becomes clear that the life that we can offer is not one that would be acceptable to the patient," she writes. According to Lamas, this kind of death is planned for, occurring only after the medicines and machines keeping the patient alive are withdrawn.
"It is a strange thing to plan a death, but I have come to understand that this is part of our work in the I.C.U.," Lamas adds.
For instance, Lamas recently cared for a cancer patient who had been intubated after experiencing a flare-up of underlying lung disease. Before the patient was put to sleep, she instructed her son to "Give her a chance to get better, but if that failed, she did not want a tracheostomy tube for a longer-term connection to the ventilator or months at a rehabilitation hospital," Lamas recalls. "Her cancer was progressing, and that was not the way she wanted to spend the last year of her life."
Lamas told the patient's family that they would continue intensive interventions for two weeks, in "a time-limited trial of critical care." According to Lamas, if the patient was not breathing on her own after two weeks, she would never be able to breath without a tracheostomy tube and extended rehabilitation—a best-case scenario the patient had already deemed unacceptable.
The day before the time-limited trial was supposed to end, the patient's son and daughter told Lamas that they wanted to take her off the machines that evening if she was not going to improve.
"There is something uncomfortable about these conversations, where it feels as though we are asking family members to plan the end of a life," Lamas writes. "It begins with a moment in the family meeting, when we have made the decision to 'transition to comfort,' and family members ask me what comes next." However, "What they are asking, really, is how their loved one will die," Lamas notes.
The 'principle of double effect'
After loved ones have made the decision to "transition to comfort," Lamas explains the next steps. "I tell them that when they are ready — as anyone really can be for any of this — we will stop the medications and the tubes that are prolonging life," she writes.
In addition, Lamas explains that the bedside nurse will administer other medications to ensure that the patient does not experience pain. "Sometimes they ask if this medication will hasten death, and I explain that it can, but that our primary goal is always to relieve discomfort," she adds.
Doctors refer to this balance as the "principle of double effect." According to Lamas, doctors "accept the risk of a negative consequence like hastening death, so long as our intended outcome is to help the patient by alleviating symptoms."
Ultimately, the pain-relieving drugs doctors administer during this process do not cause a patient's death. Instead, they ensure that patients are as comfortable as possible while dying from their underlying disease. (Lamas, New York Times, 7/31)