I was recently struck by the term quality of death.
Of course we are more familiar with the notion of quality of life. It usually implies that we should strive to prolong a basic quality of existence until our lives near their end. It implies that we and our loved-ones should consider various options when it comes to medical treatments, procedures and medications as we advance in age and frailty.
The concept of quality of death, I believe, is a natural consequence of the process. It emphasizes the real meaning behind the topic–how we and our loved ones die. I understand how difficult this topic is for most of us. Death is that 800lb gorilla in the room that we pretend isn’t there. My readers know that I do not regard the issue of death as morbid or depressing. I feel it should be regarded as the unequivocal reality that it is. It should be seen as important as life insurance and estate planning. Do we relish the idea of discussing death? Of course not. Is it necessary? Certainly.
Generalizations are always easy to discuss. Dealing with real people and their families when these issues arise are far more complex. There will never be a formula, an algorithm which can be applied to any individual life. This difficulty often dissuades us from attempting to deal with end of life/ approaching death topics. This is a mistake.
The consequences of putting off serious discussions leads to last minute grasping for choices, emotional stress which is immeasurable, family infighting and literal chaos. The risk is also that regret may follow after a loved-one dies. As a physician (and metaphysician) I have seen this throughout my over 30 year medical career. As a human being who has experienced the loss of loved-ones I know it on a first hand basis.
On recent case stands out in my mind (there are thousands very similar to it). I was called in to evaluate a 60 year old gentleman with gastrointestinal bleeding. It is a common problem that gastroenterologists deal with. But upon reviewing his record it turns out that he is suffering from metastatic cancer–from two separate primary lesions! His wife had just approved him to be a DNR (do not resuscitate) which also implied an end of life understanding. I decided not to perform an endoscopy (a scoping into the upper gi tract ) or a colonoscopy on him because of this situation. I spoke to the wife and asked her if she had considered Hospice for him. She said that she did and would contact them immediately. Now this patient was in the ICU receiving intensive care nursing, blood transfusions and extremely expensive medical/nursing care. Did he belong there? No. Did her or the family want him to die in the ICU setting? No. I encouraged them to let him go home and receive palliative/Hospice care. Was I doing this for financial reasons? On the contrary. I am compensated for doing procedures, not talking families out of them. But was that the ethical approach? Absolutely.
This situation is occurring as I blog this piece in thousands of hospital ICU/CCU settings across the country. The cost to families in terms of emotional strain and struggle, the financial burden to the health care system is immense as well. Should resources be re-directed to individuals who lack insurance but who would truly benefit from them? Again, absolutely. Is this an example of a “death panel” decisions. Of course not. The problem is endemic within the health care system. Fifty years ago it wasn’t. Medical technology didn’t exist to prolong life. Now it does. Now the discussion needs to be whether or not to use the technology when it is no longer appropriate to do so. The issue is complex with ethical, religious, spiritual, and economic ramifications. And it applies to health care providers such as physicians as much, if not more, than anyone. How do physicians direct their patients regarding such decisions? Are we at all objective? Do our own beliefs and fears come to the fore? Do we need to look within ourselves at our own attitudes and beliefs regarding the issue of quality of death? Absolutely. But we need to address them–as individuals and as a society.
The issue of quality of death should move to the forefront of societal discourse as for health care providers. Personally, I would like to find a way of becoming a part of that discussion.