Lying to ourselves: the clinician’s perspective on end-of-life care (part II)

[Continued from Part I]

Weighing the harm versus benefit of a decision is a vital part of exercising medical judgment. Crucial to that process, though, is acknowledging to whom those benefits and harms accrue—because it changes the calculus.

Cui bono?

In a classic example, we might tell a patient that, in the event of their cardiac arrest, we find it unlikely that CPR will be successful at restoring circulation. Since the odds of success are low, while the harms are substantial—the pain and discomfort of chest compressions and intubation, the indignity of an aggressive resuscitation—it doesn’t seem worth the candle.

But wait. Who’s really suffering during CPR?

The patient? They are not conscious, except in rare cases. Their low-flow state produces sufficient anesthesia that we would even consider it ethical to perform, say, an open thoracotomy without additional sedation. So can we really say that they suffer?

They might dislike the aesthetics of being stripped naked and treated like a trampoline. But again, when it actually happens they will be unlikely to notice, so this is more of a prospective, notional preference, like requesting an open-casket funeral instead of cremation. That sense of post-mortem dignity may be what some patients care most about, but is it why we’re so unhappy to run that code?

No. We don’t want to do CPR on the 90-year-old because it doesn’t sound like fun to us. The chance of benefit is small, and the whole thing is distasteful: probing needles, flying secretions, and violent compressions on a slight, elderly frame that seems like it should be left in quiet repose. We don’t care for it, so if we don’t have to do it, we’d rather not. We are the ones who suffer, along with any family who may be present.

The same math applies to less extreme cases. Consider the potential outcomes of curative versus comfort-oriented care:

• The Save: If we aim for cure and succeed, we feel great!
• The Failure: If we aim for cure and fail, it’s a shame (although a common one).
• The Hospice Patient: If we aim for comfort and succeed, we feel good…
• The Failed Hospice Patient: This is more or less a non-entity. We can almost always produce comfort if we accept the potential consequence of a shorter life.

By this reckoning, successful curative care is high-reward—but for many of our patients, extremely unlikely. Successful end-of-life comfort care is not quite as rewarding for us, but it’s not bad, and is far more likely to succeed. In other words, it’s hedging our bets. From a game theory perspective, we are incentivized to pursue comfort when the odds of cure are poor.

One might argue this is true from the patient’s perspective, too. But the math is not the same. For them:

• The Save: If they aim for cure and succeed, they get to live!
• The Failure: If they aim for cure and fail, they die.
• The Hospice Patient: If they aim for comfort and succeed, they get to die comfortably.

In other words, the patient’s perspective has an important difference: their life is on the line, not just their immediate pleasure. Although we are glad to save a life and bummed to see death, prolongation of life is not nearly as motivating for us as for the patient. Conversely, we hate to see suffering, and hate to treat moribund patients—it is depressing and uses few of our skills—so life-prolonging care of “gomers” causes us distress (not as much as the patient experiences, but plenty of it).

The end result: because of our relative relationship to disease, we may be inherently less motivated than patients to pursue low-probability cures, and more motivated to pursue high-probability palliation. After all, it’s not our life.

When the tables turn

This shifting of perspectives can be demonstrated when clinicians become patients themselves.

Although we saw that when prospectively polled, a majority of physicians would favor DNR status, that’s when it’s being asked as a hypothetical, like the old joke:

A preacher walks into a bar and approaches the first patron he sees. Tapping him on the shoulder, he asks, “Do you want to go to Heaven?” The man affirms. Walking up to the next bar-goer, the preacher asks, “Do you want to go to Heaven?” He does. The preacher continues throughout the bar until he reaches a fellow waiting by the payphone. “Do you want to go to Heaven?” he asks. “Heck no!” the man answers. The preacher is surprised. “Son, why would you not want to go to Heaven when you die?” “Oh, when I die,” the man says, relieved. “I thought you were filling up a bus to go there now.“

When physicians actually approach the end of their life, what happens? It appears they handle it very similarly to lay people. Rather than quiet acceptance and a dignified death at home, they are hospitalized just as often as the rest of the population, and spend just as long in the hospital—even a little longer in the ICU. (They do use slightly more hospice, perhaps due to greater awareness of the resources available.) In short, they seem to medicalize and rage against their death just as much as anyone. “… fear and avoidance of dying are strong motivators of much of our behavior,” note Matlock et al, “and perhaps we as physicians are not immune to these fears of dying.“

It’s clear, then, that a low chance of survival is not intrinsically a reason to stop life-prolonging care. But maybe a low chance of survival with an acceptable quality of life is more helpful. We’ll turn to this question in Part III.