Monday, February 18, 2019


You ever killed someone?

I have.

Of course, "kill" is too strong a word for what most doctors have done at some point, but still, he died because of my direct actions (a nurse and respiratory tech were involved, too).

He was a retired farmer, around 80. Strong and healthy for his age. I was in my early 30's, just out of residency and starting life as a newly-minted attending physician.

He'd fallen from a ladder and severed his upper cervical spinal cord. He was awake and alert, but completely paralyzed from the neck down. He couldn't breathe on his own, so was facing the rest of his life on a ventilator, requiring complete care for everything. There was no hope for recovery.

In the first days of the injury the trauma and neurosurgery people worked their magic, stabilizing what was left of his neck, converting him quickly from a ventilator tube to a tracheostomy for comfort, getting a feeding tube in.

As the days went by and we began decreasing his medications it became clear that he would live, was mentally intact, and could communicate with us.

In spite of what his family had told us, he wanted to be let go. He'd led a robust life and didn't want to spend the rest of it in this condition. He was ready to have things turned off so he could pass.

This sort of thing is (comparatively) easy in someone with advanced dementia, or severe brain trauma, or end-stage cancer. But in a guy who was fully awake and who'd been healthy and vigorous a few days earlier it was a whole different matter.

The family was unhappy, but acquiesced to him. To cover myself I had a psychiatrist interview him and ordered a consult from the hospital ethics committee. All agreed that he was pleasant, had a good sense of humor, and was fully capable of making this decision.

The family didn't want to be in the room when it happened, so we gave them all the time they needed to say goodbye.

When the time came we chatted briefly, and he thanked me and the team who'd taken care of him. He even asked that we shake his hand.

I had the nurse give him megadoses of morphine and Ativan, to put him to sleep and take away any pain that might still be there. Once he was out the respiratory tech disconnected him from the ventilator. Between the medications and his non-functioning diaphragm he went pretty quickly. I wrote a death note and moved on to another case. There are always more consults.

What would you call it? An execution? Physician-assisted suicide? Compassion? I'm sure some out there would love to have me tried for murder, but I don't care.

To me, my responsibility is to the patient. This man had lived a good life, wasn't suicidal in the sense of someone who's depressed, and made a rational decision about his own existence. I did everything I could to make sure there wasn't a good reason NOT to end his life, and did what I could to respect his wishes and relieve his suffering.

That was the first, though not last, time I've had to face this situation. We may become more experienced, but it never gets easier.

It's been 20 years, and I'd still say the same thing: In the end it wasn't my decision, it was his. I just did what was right for the patient.


Oldfoolrn said...

Ultimately, it was his spinal cord trauma that caused the death.

I was once accused of murder by another nurse because the mother survived and the baby did not when our surgical team lost a near full term infant to a mother that was hemorrhaging from a bizarre aneurysm. The nurse making the accusation was purportedly pro life based on her Catholic religious beliefs. My defense was based on the fact that at least the mother survived.

Things like that stick with you whether they are factual or not.

Anonymous said...

Here in Canada we have a new law for end of life decisions. MAID - Medical Assistance in Dying. Patient (of sound mind) chooses their own death, if they so desire, in cases of no hope of recovery from whatever their ailment is.
Not everyone approves, of course, but it's the patient's choice.

Anonymous said...

I refused to let them place a peg tube in my grandmother. She had dementia, had broken her hip, and then been mismanaged at the rehab center until she had an inr of 10 and had what we can only assume was a hemorragic stroke that left her unable to speak. One dr wouldnt do a swallow study until she had the tube tube in and the other didnt want to do do another study until the swallow study was done. Do I simply refused to let them place the tube, and had her transferred to a hospice house. She passed away within 2 weeks. I still have nightmares about making that call. But if she had that tube placed she would have been lingering and suffering at that rehab ...

clairesmum said...

Patients who are competent have the right to refuse treatment - I don't see any problem.
Medical care today is so micromanaged that it would be difficult to take the same course of action today, I'm afraid.

Cathie from Canada said...

I was a teenager when my aunt died in hospital -- she had severe brain damage due to alcoholism and a series of strokes. After her final seizure, I remember the doctor calmly telling my mother that "we could have kept her breathing but there wasn't any point" or words to that effect, and everybody was OK with it.
I think every family has a story like this, and thank heavens there are doctors like you who will help.

Anonymous said...

I'm with your patient & you, Dr. Grumpy. I'm 65 & not in the best of health. Not that I think I'm going to die soon, but I want to die on my own terms. I'm in the process of filling out my advance directive & quality of life is a big part of it for me. It is difficult, tho, putting it the right words. I don't want anyone to feel guilty about "letting me go" too early.

bobbie said...

I would say your are a wonderfully compassionate, caring doctor who actually LISTENS to his pts!
I've been in similar situations, and have never felt remorse ~
PS ~ I have my Advanced Directive all filled out and notarized; family has strict instructions (in writing)!!

Ms. Donna said...

Thank you. My my doctors be so merciful when my time comes.

marcia Love said...

I think you're to be commended.

Anonymous said...

What you did was compassionate (and ethical, and legal).

tbd88 said...

I've been fortunate enough to have several relatives live past 90, and all died on their own terms to a greater or lesser extent. My grandfather was no longer all there but he had the sense and strength to pull out his ET tube. We were immediately called, and my mother said "if he had the presence of mind to do that, he's made his decision, and we will respect it." A great aunt went to the ER with abdominal pain and was told that there was a long list of things wrong; the only thing she would consent to was signing the "refusal of treatment" form. Her sister was the same.

Loren Pechtel said...

While I do think you did the right thing I'm surprised it was legal. I thought the patient could refuse life-essential machinery but not order the cessation of life-essential machinery.

Unknown said...

Thank you. I hope when my time comes I will have a Dr. like you. Those of us with a family history and the gene for Alzheimer's would love to have the right to choose when to end ourlives,and hope that medical ethics will catch up with the reality of a living death sentence.

Anonymous said...

My mother is dying an inch at a time. She is done but her heart keeps going. Begs every day for someone to help her. I sob as I drive home thinking we treat dogs better than this.

Anonymous said...

I'm a Critical Care RN.

I've been witness and part to events like this, and I understand why this weighs so heavily.

In most cases, we deal with the family members/POAs who direct care for the moribund patient. When they say "s/he wouldn't have wanted more," it feels like an easy decision to discontinue the supports.

It's so much harder with an alert, decisional person who says, "I don't want more."

Their decision is deliberate, and intentional, and that makes your actions, under their direction, feel the same.

Anonymous said...

You did good Dr. G. As a small animal vet , i've helped many suffering little ones escape their pain and fear. When my mom was dying of metastatic lung cancer and she told us she didn't "want to do this anymore", i used the hospice-provided drugs (morphine, fentanyl, and ativan) every 2 hours until she eased into a coma and died gently. I helped kill my mom and i am grateful that i could help.

Packer said...

80 year olds on ladders =bad ending. My old man did the half gainer from the roof at 81, sub dural hematoma. Skull drilling , 3 days later massive stroke, ventilator, 10 weeks in hospital, completely paralyzed left side. 6.5 years in care facility. Every week for 6.5 years on my visit I heard , what kind of son are you leaving me here like this, take the pillow and do what needs to be done. Some visits he was unrelenting, two hours of constant loud
Demanding that I score heroin or pills to do the job, swearing , pleading, crying. I was a f*@#ing worthless child. Every Thursday night for 6.5 years I would leave there with a headache. All I could think about was his constant misery and what a worthless f*@#ing son I was.
If I had to do it over I would have said no ventilator at the start.

Think about this next time you want to clean the gutters

Anonymous said...

I have had the DNR choices conversation with my 92 yo Mom and have the paperwork in place. Pre-hospital advanced life support agencies in our system have the ability to honor our palliative care form, which limits life-prolonging therapies chosen by the patient, when documentation is presented.
If your story didn't weigh on you, you wouldn't be human.

Anonymous said...

Catholic ethics agrees with Dr. Grumpy here. Crucially, the man was alive only because of extraordinary medical treatment (well beyond the needs of the healthy body) which was burdensome (unusually difficult to endure and unusually expensive, with no hope of improvement). You are not required to continue such treatment.

Anonymous said...

A compassionate, ethical, and very appropriate action. Been there, done that. Dr. G has met the highest standards of his calling. First, do no harm.

Anonymous said...

Just because you CAN, doesn't mean you SHOULD. The experience you describe must have been difficult for everybody, but it was the right choice. Especially because the patient chose it. Quality of life is just as important as quantity of life.

Andy P said...

I've seen this from both a professional and personal perspective (I'm a hospital pharmacist). Both events happened within the same month, 10 years ago.

The personal case was my dad. He was diagnosed with gastro-esophageal cancer at the age of 58, right at the bottom end of the usual age group. Initially it looked curable, and the plan was chemo to shrink the tumour followed by surgery. Despite chemo, the tumour metastasised to the spine and probably liver, and survival plummetted to less than 12 months. I last spoke to my dad the day after Father's Day 2009; we lived a two-hour drive away so visited at weekends. He'd been going a little bit downhill but the plan had been for him to spend some time at the local hospice and then perhaps come home (to die). The following Friday, I was at work and got a call from my brother to say that he'd deteriorated and the hospital were withdrawing treatment - I never found out exactly what happened, but it sounds like he had a massive haemorrhage and was iminently dying.

We rushed to the hospital, and got there at around 6pm; my dad was terminally sedated with a morphine and midazolam syringe driver, and we sat round his bed waiting for him to die. It was the day after Michael Jackson had died, so while my mum was out of the room I shared some of the *inappropriate* jokes that I heard or read recently.

The following day, he died at around 15:00. I'm pretty sure the hospital staff helped him go, as maybe an hour before they had been in to change his syringe driver and I'm sure they probably increased the drug doses or rates. I think the nurses came in and saw that we'd said everything we needed to, as we were sat in silence, just waiting. And I think they made the right decision, as letting things drag on would have been cruel to my dad (and us). I also know my dad would have wanted to be helped on his way when things became hopeless.

I went back to work, and started my first hospital job at the end of July. I was an antimicrobial pharmacist, so rounded with the Medical Microbiologists. We always started the round at ICU, where we reviewed all of the patients with infective issues with one of the critical care consultant physicians. Our very first patient was an elderly lady in her 80s, with a whole host of other conditions, and had been admitted a few days earlier with infection. She'd deteriorated and been transferred to ICU and ventilated, but suddenly became unresponsive. She'd had a massive stroke, and was brain dead. The clinical team made the decision to switch off the ventilator, and she had slipped away before we had finished the round. I don't know the intricate details of whether or not she had a Advance Directive or similar.

I think that both my dad and the lady who's name I never knew really changed my outlook; since that time I have embraced my religion (and am currently thinking about another career change, to become a minister). I've always believed that we should protect life wherever we find it, but now when I pray for people who are ill, I ask for healing but also for a good death if their time has come.

A. Marie said...

My husband did for his father what Anonymous@2.19.19@9:33 am did for his/her mother: DH was on middle-of-the-night duty for Pop, and just gradually increased the morphine dose till Pop stopped breathing. Dr. G., you did the right thing, as you know. I hope that DH and I will have someone like you around when it's our turn, although we've put our wishes in writing as explicitly as we can.

Anonymous said...

Thank you for helping the man get the relief he asked for. I need to get my advance directive together and this is a reminder.

Anonymous said...

As a veterinarian, I hear from many folks that they always wanted to be a vet, but couldn't handle the euthanasia part of the job. My stock answer is that my profession is to help owners and their lovely pets, and sometimes I am helping the most when I end the suffering. Not that it's easy, it should be hard and memorable, just as this case was for you.

The Scrivener said...

When I was an intern, there was a young man in his 20s or 30s who had been in a terrible car accident and was vent-dependent. He was constantly in and out of the hospital with trach infections, bedsores, etc, and every time he made it really clear to the medical team that he did not want to live like this. He started pulling out his trach, which would of course sound the alarm and everyone came running and reinserted it, and two or three days later he'd do it again.

After about six months of this, I'd heard he finally passed after one of these self-extubations, and the only thing I could think was "Good for him."

Anonymous said...

Part of the really living is the not forgetting. At least while you can remember to pass it along. I thank the goodness in this world that there are those of us around to respect and retain the dignity of really living.

When my father was in the downward spiral, dependent on oxygen, he occasionally 'forgot' that his air was coming through a little tube and when it became disconnected his sats quickly dropped, and he became more and more confused. As an Army veteran, he was cared for by an Army doctor employed by the VA. The doctor stopped by the house for the first visit while I was visiting from out-of-state.

A few years before I'd visited Central Europe and stopped in the magnificent bookstore Books Dobrovský in St Wenceslas Square downtown Prague, and after looking around for a book published in a language I could read right away, purchased a book recommended by the bookseller, The Good Soldier Švejk by Jaroslav Hašek.

My father never was one to say much, but I could tell the satire appealed to his funnybone, and it just so happened that when the hospice doctor arrived, that book was sitting on the couch. I thought how happenstantial the doctor recognized it right away as he'd emigrated from Czechoslovakia as a youngster with his family. Something in common to communicate without need for understanding or logical reasoning.

Anonymous said...

We have done the same with both of my parents. It was a blessing.

Anonymous said...

A remarkably similar injury (different causes, car accident) and outcome happened to my father in law last year. He/we are catholic, and while this doesn’t influence you, we are not bound ethically to receive extraordinary treatment to prolong life if it’s not wished for. When the time came and they were going to put him on a vent, he was lucid enough to understand what was happening, expressed his vehement refusal to be ventilated, and passed not 12 hours later. With such a grievous injury, treating with compassion/comfort is the best thing medical staff can do. You did your best caring for that patient. Thank you for helping him in a difficult situation to approach the injury on his terms.

Rich said...

Thank you. I more than likely will at some point make a similar decision that this man made. I got a hernia back in 2002, and the doctor made some life-altering mistakes during the first surgery and additional mistakes in the second surgery six months later. It took me another two years and tons of tests later to get my third surgery and the doctor at that time medically retired me due to all the nerve damage. I was 37 when I had to retire.

Since that time I've put on 100 pounds of weight and due to compensating for my pain in my right groin I've screwed up my back, hips, and knees. I'm under a doctors care getting good help but the pain is still there and always will be. I wake up at a pain scale of 7 and unless there are some dramatic medical advances I will always wake up a pain scale of at least 7. I'm hoping that I continue to be strong enough, or stubborn enough to make it until my grandkids ages 7 and 10 graduate college or better yet get married, hopefully after college.

I don't say of this for people to feel bad for me or for somebody to say you have to try this. I say this because it takes courage to do what did and hopefully if I ever find myself in a similar situation where the quality of my life isn't as good, that I find somebody like you to help on that final Journey.

So again, thank you.


Loki said...

Thank you for the compassion you showed there, and the respect offered to that man.

Moose said...

This is a mitzvah. I hope when my time comes I have a doctor with your compassion.

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