Talk About Death - It Won't Kill You

A patient in his late 80s with chronic heart failure was presented to the Emergency Department. He had low blood pressure, trouble breathing and chest pain, and it was decided that he would need intensive monitoring of his vital signs with frequent medication adjustments. He was destined for a room in the ICU. 

For whatever reason, however, the admitting cardiologist failed to discuss a ‘code status’ with him before sending him to the ICU. 

That small error had tragic consequences. 

In the ICU, his blood pressure and heart rate continued to drop despite maximal medical intervention. Soon after his arrival, he went into cardiac arrest. As the code started, I was rotating turns to do chest compressions. Each compression cracked another rib, which is what should happen to effectively pump the heart to circulate blood to vital organs. 

In between chest compression rounds I looked up and saw his wife.

She stood at the edge of the room, watching the chaos with a look of shock on her face. She had not been prepared for the possibility of this event, and approximately 10 minutes into the code, she cried out for us to “stop everything” and “just let him go.” 

I still recall the look on his face as I stopped the compressions. 

An intubation tube was coming out of his mouth, and I couldn't help but to imagine how this situation could have all ended differently. I approached his wife to give her my condolences. 

"All he would have wanted was to drink one last Pepsi and pass peacefully with his family nearby," she said, tears in her eyes.

In the 3 years that I worked as a certified nursing assistant in an ICU, I witnessed “good deaths” and I witnessed “bad deaths”. You may be asking yourself: "What’s the difference?, Aren’t all deaths are bad?"

My experiences in the ICU taught me a lot, but what made me passionate about end-of-life planning was the unfortunate number of times I watched patients and families struggle to make life-or-death decisions that could have -- and should have -- been made at a more opportune time.

To this day, I get emotional when I think about the cardiac arrest codes I have been a part of.

Imagine spending your very last moments with your loved one watching their clothes get stripped off in front of strangers as someone pushes on their chest so feverishly that the ribs beneath break; tubes are being inserted in almost every orifice, while a monitor alarms and nurses and doctors shout about what has been done and what can be done next. Some loved ones watch in horror, while others retreat to the waiting room.

Imagine that as the final memory you’re left with.

And that memory stays with you forever.

At the other end of the spectrum, I’ve seen families gather around their dying loved one to spend time together in a peaceful environment while everyone present rests comfortably.

And there's one thing that can make either of the two potential endings become a reality for yourself or a loved one: thinking ahead.

Until the final decades of the 20th Century, death was viewed as an expected part of life and typically took place at home with loved ones nearby. This was so common, in fact, that the parlor was considered the standard room for the deceased to lay.

Today, death has all too frequently become strictly a medical event. It often involves the use of advanced technology and extraordinary procedures.

“We as a society view death as a failure of medicine, instead of what it really is - a natural end to life.”

That change is a result our culture’s difficult and unrealistic expectations regarding medicine and death. Our society encourages us to think that that we're immortal, and that modern medicine will stave off death until we feel ready. That will, unfortunately, never be true. As Atul Gwande points out in his book Being Mortal (which I highly recommend), we as a society view death as a failure of medicine, instead of what it really is - a natural end to life. As physicians, we have the privilege of helping our patients live their best lives until the very end.  

Hypothetically, would you like a healthcare team to attempt to bring you back to life if your heart stopped beating? Most people immediately think, “why wouldn’t I want a healthcare team to try to resuscitate me?” Unfortunately, the likelihood of these resuscitation efforts being successful are low.

According to the American Heart Association (AHA), in 2016, there were 209,000 in-hospital cardiac arrests. The survival rate was a mere 24.8%. 

The AHA reports an even worse survival rate of just 12% in 2016 for cardiac arrests that occurred outside of a hospital setting. These statistics should be considered in light of the diminished quality of life that is regularly experienced by survivors of cardiac arrests. 

Another 2016 study published in the Journal of the American Medical Association (JAMA) showed that more intensive and invasive care was not shown to extend the length of one’s life. Nor did it improve quality satisfaction scores from family members of the decedents. In fact, the opposite is true. Those with serious illnesses on hospice have been shown to live longer and be in less pain. Their loved ones also report less grief compared to those without hospice or palliative care services at the end of life.

I am not trying to dissuade anyone from full resuscitative efforts. Instead, I hope to show - through evidence and my personal experiences - that there are no easy answers to end-of-life questions. My hope is to encourage patients to make informed decisions and have their wishes clearly laid out and accepted by their loved ones. This simple change can save resources, stress, care-giver burnout, and perhaps most importantly, heartache.

Modern science has forced the field of medicine to step into age old philosophical debates about life and death.  In just the last 100 years, the average life expectancy has increased from 54 years in 1917, to 81 years in 2017. Although we’re living longer than ever before, the issue of managing advanced age and chronic illnesses has not advanced as much as the medicine that increased our average life expectancy by an additional 27 years.

Advance care planning continues to grow more important as medicine continues to advance. Increasingly we are placed in the crosshairs between science and philosophy.

What does it mean to you or your loved ones to be “alive?" If you had a say in how you wanted to leave this world, what would your preferences be?

The sad truth is that we will all leave this world someday. The difference is how we leave it.

Planning your care in advance can be a gift to you and your loved ones. My advice to patients is to take control of their destinies, think ahead, and to make their wishes known.  

Note: This blog was written as part of preparation for “What Matters in the End” week March 26th-30th, 2018. For more information on the "What Matters in the End" reception, which is open to the public, click here.

Kathryn Buckman

Osteopathic Medical Student - 1st Year (OMS I)
College of Osteopathic Medicine
Pacific Northwest University of Health Sciences