Obels for Charon


On the last day of her life, your mother went on a spending spree. I intubated her at around 9AM and for the rest of the day we threw money at her, successfully keeping her alive until about dinner-time when her liver cancer finally had enough, gave us the finger, and showed us who was really in charge. It was not a pretty death, but then I knew it wasn’t going to be when I only just managed to jam the breathing tube through her vocal chords before they were obscured by blood and other unwholesome-looking fluids. Still, over the course of a very interesting day she got an expensive bronchoscopy , five or six lab draws, a central line, an arterial line, three units of blood, a chest x-ray, continuous nursing, pumps, fluids, two consults, monitors, blinking lights, and the usual buzzes and beeps.

We did everything but put a coin under her tongue for the Ferryman which, considering the outcome, would have been just as cost-effective.

The next time, please pay attention to what we have to say when we have “The Talk” like we did two weeks ago to tell you that your mother had passed beyond the limits of our abilities and all we could really hope to do was to ease her suffering as she died. Unfortunately, as we live in an egalitarian age which worships your autonomy, when you seemingly ignored our advice and said, “Do whatever it takes,” our hands were tied and we committed ourselves to two weeks of slowly torturing a dying woman. I understand how you feel about your mother. I have a mother too but you can’t have really wanted this. We coded and shocked her, what? three times in the last eight hours? It had to have hurt her the first time when there was actually something of your mother to bring back. After that, well, I just don’t know.

Not all life is priceless. Not even your mothers. When you said, “Do whatever it takes,” what you really meant was, “Do whatever it takes as long as I’m not paying for it.” But there are very real costs associated with medical care and somebody is paying them. I don’t mean to lay this burden on you but since you want the autonomy to make medical decisions, you need to have all of the facts. Would you have ignored our advice if you had to mortgage your house to pay for your mother’s last two weeks of futile care?

Medical care, like most resources, is scarce and there’s never going to be enough to go around. Somebody has to decide how it’s going to be allocated and for better of worse we seem to have elected you even though you seemingly have no interest or incentive in the matter.

I don’t think you made a good choice here. That’s all. Medical care is for the living. Your mother needed hospice and maybe to die at home peacefully.

This doesn’t mean I don’t think we should spend money on the critically ill. I don’t know how much a year or two of life is worth and we certainly get sick but otherwise highly functional patients who we can return to a happy and meaningful life. I’d hate to make that kind of decision based on simple economics, assessing the value of a year with actuarial exactitude and making decisions accordingly. On the other hand there is a difference between critical care and futile care. Maybe I can’t define the exact line separating the two but I know the difference when I see it. Perhaps you were too emotionally involved to make the distinction and it was unfair to leave it up to you. It’s hard to let go, especially as the popular culture has conditioned us to expect medical miracles although I don’t know what you were expecting with your mother. The eventual outcome had never really been in doubt and you knew perfectly well that you mother was not going to be leaving the hospital this time.

When I pronounced you mother and closed her eyes for the last time, the ancient stillness of the tomb was deafening.

15 thoughts on “Obels for Charon

  1. Just a questioning med student here.
    During lecture in my second year, I thought I remember them telling us that docs are not required to do anything that they think is futile just because the family asks. Is that not true? Where is the line drawn? Certianly, a doc is not required to transfuse a brain-dead (yes, I know – brain-dead is dead, but think colloquially here please) patient just because her Hgb drops to 4 even in the family wants it done. I know this is an extreme example. Hence, the sescond question above. Your thoughts?

    Also, I think the new page has a nice look.

  2. Hey Panda Bear,

    Great stuff. You have leaped to the top of my favorite blog list (don’t tell poor Gruntdoc).

    I do have a quibble. You wrote, “assessing the value of a year with fiduciary exactitude” and I suspect you meant to say actuarial exactitude. The reason I bring up such a petty point is that I was recently impressed by Joe Lex’s comments about the physician patient relationship being a fiduciary one. If anyone is interested and has access to emedhome.com the podcast Nofreelunch by Dr. Lex is highly recommended.

  3. Howdy Panda,

    Wanted to de-lurk for a second to let you know how good I thought the new site is. I’m a second year med and your articles over the last year have given a ton of laughs and a ton of insight. Thanks for taking the time to do this, despite your schedule. I know it’s got to feel like hell sometimes but the time you take to pass wisdom down to the up and commers is damn sure appreciated. Thanks, bro.


  4. Panda, another great post. Torturing sick people is not the main reason I went into medicine. But why drop your USMC id from the site? I enjoy it every time I visit. Take care and keep up the good work. rural_obgyn and mom of LCPL in Iraq

  5. I don’t know–I might give people a break on this one. People can get irrational when it’s their loved one. I’ve witnessed hundreds of family members discussing end-of-life issues with doctors about their parents—and all of them had that “deer in the headlights” look where logical thought seemed to fly out the window. And although you might have explained things very clearly regarding the prognosis, I’ve also seen cases where the doctor seemed to hem and haw, hedging reluctantly, and wasn’t as clear—thus leaving the family members confused and unsure about whether or not the care that was available might help the dying person or was “futile”. (And I speak from experience because I, myself, lost all reasoning when it was my own father dying—and I will confess that I now look back on my behavior at that time with shame and embarassment because I was rude to my dad’s doctor who had been perfectly clear and honest with my family about the situation.)

  6. Panda:

    I’m a long-time fan, and love your writing!

    My fellow MS-1, on the subject of career fields, insists that it is illogical to consider EM but not FP, because EM is mostly FP for the irresponsible and/or uninsured.

    I didn’t argue the point with him (because an argument between two people entirely without expertise is fairly pointless), but I did wonder… you know about both career fields, so I thought I’d submit the question to the Panda.

    To what extent, and in what ways, is my friend’s assertion true and untrue?

    Clueless but Working On It. 🙂

  7. Your friend is so full of shit that his eyes are brown. While it is true that there is some overlap between family medicine (primary care) and Emergency Medicine, there is overlap in every medical specialty.

    I’m going to elaborate on this in one of my next posts (and I’m glad you asked) but for the time being, let me just observe that the patients I see on a routine basis as an Emergency Medicine resident and who don’t even raise an eyebrow are much, much sicker than anybody I saw as a Family Medicine resident in clinic.

    I typically end up admitting at least two patients per shift to the ICU, for example, not to mention the thirty percent or so who are admitted to the hospital. In 48 FM clinic days last year in FM, I only sent two patients to the hospital.

    In fact, the first impulse of most family physicians when they encounter anything even remotely squirrely is to send the patient to the Emergency Department.

    The issue is that Family Medicine pays very poorly and many FPs would prefer to do EM as it pays almost twice as much for fewer actual hours of work. An FP might start at $130,000 for a 45-hour week while an EP usually starts at $220,000 for the equivalnet of a forty hour week.

    Unfortunately, EM is a good deal more competitive than FM so not everybody who wants to work in the ED can get board ceritfied. When an FP downplays the need for a separate Emergency Specialty, what he is really saying is that he does’t think it’s fair that primary care reimburses so poorly.

  8. Hey there Panda just wanted to ask if you were going to have a RSS feed to your site again (you did at one time anyway). I really like receiving your blog in my feeds so I can keep up with your site but it is a little easier for me to remember. Your blog is something that keeps me going in my Medical School quest. Am I a glutton for punishment or what? Thanks for all your advice and or support.

  9. This is an excellent post and something that every patient and relative of a patient should read. This is an example why physicians blogging is a good idea.

  10. Liking the new e-home (and this post, of course); glad to see my redirect idea worked for you.

  11. Panda,
    strong work as usual. Your blogs are always entertaining and resonant with insight. I find your posts strip away alot of the rhetoric and fanfare that adcoms and the greys anatomy gestapo would have naive med. students and pre-meds believe. Your pragmatism and experience is refreshing and well received. Required reading imho. take care.

  12. G’day Panda. I remember thinking, several months back after completing my geriatrics rotation, that your average person has almost no idea what it means — what it *really*, really means — to be old and sick. I also made the decision that when I get as old or as sick as some of my patients were then, the first words coming out of my mouth are going to be: “DNR, DNI.”

    And, I think moreso than the financial issue of other people paying for care which you raised in your post above (though it is very true — 30% of our lifetime health expenditure is incurred in the last three months of life), the problem of not understanding what it means to be dying is prevalent among many members of our society. Moreover, I think the medical profession is in some ways failing our patients by giving them too much autonomy in this regard. One thing that has struck me in recent days is that, as doctors, we do far too much “advising” and far too little doctoring, to the point where it seems to some of our patients that it is THEY who need to make medical decisions and we who merely carry them out. I don’t mean to be patriarchal about things, but perhaps our cultural trend of offering our patients “options” and leaving them to choose, even when we know that some of the options we are offering are medically useless and bordering on torture, isn’t really the right way to go about things.

    Cheers Panda, hope residency continues to treat you well.

Comments are closed.