Sunday, August 22, 2004
Playing God
zena raises the question of Doctors playing God in her entry dated 20 Aug 2004. I initially meant to post this on her blog in response, but her !"$%!ed comments system only allows 1000 word posts, and after eight attempts to break this into suitably bite-sized chunks I decided to sod it and write it all in its entirity here on my own blog.
So this one's for you, zena.
*****
I used to feel exactly the same way, watching my team make exactly those decisions as a pre-reg house officer. One of the worst memories I've ever had was in the first few weeks of my job, when one of the patients died for precisely those reasons - and rather unnecessarily. I still feel that way, and I suspect my team made a mistake which I didn't agree with. But I came to see that the converse was also true - much of the time the team was right.
As one matures in the profession one begins to realise that it's not so much a matter of unworthiness, power to the doctor, or even playing God - sometimes it truly is a matter of compassion.
You'll understand one day when you have to make that decision yourself - perhaps when you're crash-bleeped to resuscitate a 90something year old with cancer, and break half her ribs in the process because someone forgot to make a decision about resusc status, or perhaps when you meet that end-stage COPD patient who's clearly not going to make the night, and caught in that fine balance between hypoxic agitation and hypercapnoiec narcosis - what do you do then? let nature take its course and let him die flailing about in agony, with his wife in tears - or crank the oxygen up just a tiny bit and send him off to sleep forever?
Perhaps you won't be as unlucky as one of my colleagues who had to deal with a fortysomething year-old veteran of the vietnam war, whose exposure to agent orange had utterly destroyed his liver years later and transformed him into a walking skeleton on his last legs.
In his final days he was too weak to stand, and gradually becoming too weak to breathe. He wasn't long for this earth - yet against all advice, he wanted us to resuscitate him.
Do you know what the doctors did? They resuscitated him. Inappropriately. (He died after 20 minutes of CPR) DNAR orders can't be applied to a patient against his or her will no matter how futile the outcome will be. DNAR orders in themselves aren't evil - it's the misapplication of them that opens cans of worms.(eg maintaining a DNR order against a patient's wishes.)
I used to ask : how are we to know when a person is going to die?
The answer unfortunately is we can't, as doctors. We can only make informed guesses. The more senior you get, the better you get at guessing. Real medicine isn't the precise science the yanks seem to think it is - it's actually an imprecise art with a fair number of individual cases falling "beyond normal ranges".
My consultant was wrong occasionally - but he was also very often right. And so it should be - as you wrote, to err is human.
I think a fair number of doctors do accept their limitations. I find myself telling my patients a lot of the time that I don't have the answer to their questions. It beats telling them they're going to die when they're not - or telling them they'll live when they're going to die.
And I feel that there is such a thing as informed decision making - just how informed is the question - and that duty falls upon you, to as best inform your patient as you can, that he/she may make the best choice for themselves.
To decide that someone must live, no matter what - is just as paternalistic as deciding someone must die, regardless.
perhaps the best keepers of the temple are the patients themselves, provided they know exactly what lies ahead for them. A DNAR order can be appropriate, provided it's been fully discussed with the patient, who concurs with the team of doctors. Many people, myself included, would rather pass away with a modicum of dignity from their end-stage disease than suffer a traumatic but pointless resuscitation only to die from the same disease process a few days or hours later with half their ribs broken, burns to their chests and in multi-organ failure.
shrug. Maybe it's just a matter of us getting old and molded to the doctory mindset. Perhaps we play God out of habit. Or maybe it's not as black and white as you think, and perhaps the lay perception of "playing God" and "power trips" is really an intricate and complicated mix of humanity and compassion - and the problems arise when doctors who don't quite understand the rules, or don't really care enough about their patients misapply the orders.
So this one's for you, zena.
*****
I used to feel exactly the same way, watching my team make exactly those decisions as a pre-reg house officer. One of the worst memories I've ever had was in the first few weeks of my job, when one of the patients died for precisely those reasons - and rather unnecessarily. I still feel that way, and I suspect my team made a mistake which I didn't agree with. But I came to see that the converse was also true - much of the time the team was right.
As one matures in the profession one begins to realise that it's not so much a matter of unworthiness, power to the doctor, or even playing God - sometimes it truly is a matter of compassion.
You'll understand one day when you have to make that decision yourself - perhaps when you're crash-bleeped to resuscitate a 90something year old with cancer, and break half her ribs in the process because someone forgot to make a decision about resusc status, or perhaps when you meet that end-stage COPD patient who's clearly not going to make the night, and caught in that fine balance between hypoxic agitation and hypercapnoiec narcosis - what do you do then? let nature take its course and let him die flailing about in agony, with his wife in tears - or crank the oxygen up just a tiny bit and send him off to sleep forever?
Perhaps you won't be as unlucky as one of my colleagues who had to deal with a fortysomething year-old veteran of the vietnam war, whose exposure to agent orange had utterly destroyed his liver years later and transformed him into a walking skeleton on his last legs.
In his final days he was too weak to stand, and gradually becoming too weak to breathe. He wasn't long for this earth - yet against all advice, he wanted us to resuscitate him.
Do you know what the doctors did? They resuscitated him. Inappropriately. (He died after 20 minutes of CPR) DNAR orders can't be applied to a patient against his or her will no matter how futile the outcome will be. DNAR orders in themselves aren't evil - it's the misapplication of them that opens cans of worms.(eg maintaining a DNR order against a patient's wishes.)
I used to ask : how are we to know when a person is going to die?
The answer unfortunately is we can't, as doctors. We can only make informed guesses. The more senior you get, the better you get at guessing. Real medicine isn't the precise science the yanks seem to think it is - it's actually an imprecise art with a fair number of individual cases falling "beyond normal ranges".
My consultant was wrong occasionally - but he was also very often right. And so it should be - as you wrote, to err is human.
I think a fair number of doctors do accept their limitations. I find myself telling my patients a lot of the time that I don't have the answer to their questions. It beats telling them they're going to die when they're not - or telling them they'll live when they're going to die.
And I feel that there is such a thing as informed decision making - just how informed is the question - and that duty falls upon you, to as best inform your patient as you can, that he/she may make the best choice for themselves.
To decide that someone must live, no matter what - is just as paternalistic as deciding someone must die, regardless.
perhaps the best keepers of the temple are the patients themselves, provided they know exactly what lies ahead for them. A DNAR order can be appropriate, provided it's been fully discussed with the patient, who concurs with the team of doctors. Many people, myself included, would rather pass away with a modicum of dignity from their end-stage disease than suffer a traumatic but pointless resuscitation only to die from the same disease process a few days or hours later with half their ribs broken, burns to their chests and in multi-organ failure.
shrug. Maybe it's just a matter of us getting old and molded to the doctory mindset. Perhaps we play God out of habit. Or maybe it's not as black and white as you think, and perhaps the lay perception of "playing God" and "power trips" is really an intricate and complicated mix of humanity and compassion - and the problems arise when doctors who don't quite understand the rules, or don't really care enough about their patients misapply the orders.
