The patient had a severe pneumonia of advanced AIDS. He’d been lying in our intensive care unit for three weeks, a breathing tube thrust into his raw airway, his face a mixture of pain and resignation. His weakened lung tissue had popped in several areas, requiring chest tubes to drain the pockets of pressurized air. He looked like a sea creature with multiple tentacles.
My co-attending doctor in the I.C.U. had tasked me with keeping the patient alive for the weekend. “I’m going to try and get the tubes out on Monday,” he explained. Knowing the prognosis, I asked him if he’d told the family the patient was going to die.
“No. I can keep him alive for now,” he replied. With that, he left.
Soon after, the patient’s family arrived. I took a deep breath and told them what I knew they hadn’t yet heard: that his lungs had been permanently damaged and were steadily getting worse, and that he would probably never come off the breathing machine. In short, I said, he was dying.
His family took in what I said. I left them in the conference room to process this information, and a short time later his brother found me and asked that the patient be taken off the ventilator and made comfortable. He died peacefully on Sunday night.
I doubted my co-attending doctor would be surprised. My residents tell me some of my colleagues call me Dr. Kevorkian. Specializing in the seemingly divergent fields of intensive care and palliative care, which focuses on the relief of pain and suffering of patients, I frequently find myself in the position of undoing the life-prolonging work of my I.C.U. colleagues.
I believe in letting the dying determine how and when they die, as opposed to coaxing their organs along at all costs. As one of the only doctors I know who straddles these two worlds, I am struck by how many of my colleagues are surprised, even disturbed, by this pairing. I was once accused by a renowned professor of medicine of deceiving my I.C.U. patients by also practicing palliative care, as if it was somehow a conflict of interest.
The I.C.U. is a final common pathway for many of the dying. One in five people in the United States currently dies there, and this number is on the rise. Studies show that many of them suffer significantly before they die.
