Q4 24+3

You have the right to die.

I have been working in the Medical Intensive Care Unit (MICU) for the last month. The MICU is a place where most people are already in the process of dying, and as doctors, we try to do what we can to prevent them from dying. The patients are all critically ill, usually on machines breathing for them, being fed through tubes, getting poked and prodded all over their bodies. While I have been there, I have taken care of patients ranging in age from 28-96. I have seen many families agonize over making medical decisions for these patients.

Too often, families err on the side of "wanting to do everything" for their family members. I write "err" because I feel that if the family members knew what we knew and saw what we did, they would realize that often "doing everything" is torture to the patient.

The human body can only stand so much of lying around and poking and proding. Patients, unable to move, develop large sores over the dependent areas of their bodies, often down to the bone, which only creates more problems as this is a nidus for infection. Being on ventilators that do the work of breathing, leads to pneumonias and colonization with bacteria. Being intubated (having a tube in your trachea that goes to the lungs to breath for you) can cause complications and lead to narrowing and inflammation of the trachea. Therefore, many people that cannot come off a ventilator eventually end up have a tracheostomy, a hole made into their trachea. Every body function that used to happen naturally now doesn't. You are fed through a tube that goes from your nose to your stomach. However, the longer that is in, the more likely that you can have complications such as erosion into your nasal septum and possible perforation of the esophagus and erosion into the lining of the esophagus. Patients are on constant regimens of laxatives and stool softeners, they have rectal tubes placed to collect their excrement and foley tubes placed through their urethras into their bladders to collect their urine. This is another source for infection. The more antibiotics you are treated with, the more resistance the bacteria build, the more likely you will get worse infections.

I don't have the right to tell anyone that they shouldn't live their life that way. That is strictly my own opinion. But you should be able to tell people whether or not you want to live your life that way. Most states allow you to have a health care representative, a Health Care Proxy. The person needs to be older than 18, and appointed by you to make your medical decisions in a situation when you cannot make any medical decisions. As a health care proxy, the person will be informed of your medical situation and what can be expected in terms of your prognosis. Then, based on your wishes, they can make medical decisions for you. In states that do not use health care proxies, you can have an advanced directive in which you explicitly state what you would or would not want done.

I feel that it is never too early or to late to do this. In fact, I have discussed this with my husband and we are working on our forms. I urge you to be as explicit as possible about what you want done. Consider things such as feeding, drawing blood (which we do a lot), receiving blood transfusions, receiving antibiotics, whether or not you want a breathing tube placed, whether or not you want electrial shocks to be administered in the case your heart stops, or whether you want IV medications to be used. Do your research, choose your proxy wisely. They need to be someone who will act as an advocate for you and who you know will not falter under pressure and decide at the last minute to go against everything you decided you want and instead do what they want. (I have seen this in the case of patient's stating they don't want to live in persistent vegetative states, but their proxies keep asking for everything to be done.)

It's not easy to think about your own mortality, but you have the right to determine some aspects of it. You may not get to choose what cause/illness leads to your life being stopped short, but you get to choose how you want to be treated when that happens.

Posted by susana at February 23, 2005 10:39 PM