On death and dying

Jack Kevorkian has died.  From the obituary in the New York Times.

From June 1990, when he assisted in the first suicide, until March 1999, when he was sentenced to serve 10 to 25 years in a maximum security prison, Dr. Kevorkian was a controversial figure. But his critics and supporters generally agree on this: As a result of his stubborn and often intemperate advocacy for the right of the terminally ill to choose how they die, hospice care has boomed in the United States, and physicians have become more sympathetic to their pain and more willing to prescribe medication to relieve it.

I’m really not in a position to pronounce on how much credit Dr. Kevorkian should receive for the rise in hospice care.  As the most vocal advocate for the rights of the terminally ill to die on their own terms, he certainly put a visible face on the issue and kept it in the news.  Changing the attitudes of the medical community regarding how our patients die was his goal, and insofar as they have changed he seems to have accomplished it to a great degree.

There were many, many reasons for my becoming a pediatrician.  I like kids.  They’re fun to take care of, and I interact well with them.  I like being a formative part of my patients’ lives, and helping them create positive impressions of going to see the doctor and taking care of themselves.  And I really like that the vast majority of my patients will either remain in good health while under my care, or will return to it with appropriate treatment.  It’s nice to have a patient population that will almost always get better.

However, the truth that every medical provider must face is that some of our patients will die while under our care.  None of us are wonder-working wizards that can cure everything, and there are some diseases that have no cure and proceed ineluctably toward death.  It is humbling and frustrating and heart-breaking when one has to face this, but face it we must from time to time.  I have myself, all too recently.  We do no service to ourselves or to our patients if we try to deny it or hide from it.

Decisions about when to withhold or withdraw care require honesty and courage.  Too often the culture in medicine is (or, perhaps, has been) that every death is a defeat or a failure, something that could have been forestalled if only there had been some small change in management.  It’s us vs. the disease.  But patients die of their diseases every minute of every day, and preparing for it properly allows patients and medical providers alike the option of setting the best terms possible.  A death free of pain and in the setting that offers the most comfort should be available to every patient, so far as circumstances allow.

We now have the capacity to preserve the function of numerous organ systems long after the organs themselves have failed.  We can mechanically ventilate patients, give them dialysis and parenteral nutrition, and turn them in their beds to keep their skin intact.  But just because we can doesn’t mean we always should.  Prolonging the metabolic lives of those who have otherwise long since died because of an inability to face the truth that our patients will die, or because we never dealt honestly with it while they were still in a position to make their wishes known, is a failure on our parts.  To the extent that Dr. Kevorkian reminded us of this, he deserves a degree of gratitude.

(Cross-posted at Blinded Trials.)