December 6, 2010 | Posted By Sheila Otto, MA, BSN

Recently National Public Television aired a Frontline documentary on “Facing Death” filmed in a medical intensive care unit at Mt. Sinai hospital in NYC.

The program focused on several patients who were in the last weeks of their lives and who were making (or their surrogates) medical decisions. Several things struck me, even after acknowledging   that editing hundreds of hours of filming into one hour is not likely to portray the whole story. It is not my intention to criticize the caring and competent physicians whose daily work touches so many of their patients’ lives in a positive manner.

One patient had been in the hospital for months, hoped to go home (and did briefly before being readmitted) and insisted on getting more treatment in spite of the fact that no one in the family or health care team thought there would be any benefit. Our modern focus on “patient autonomy” led the team to give the impression that the patient’s choices would trump, regardless of cost or likelihood of improvement. I couldn’t help but think that the patient simply wanted to live (preferably in his pre-illness state) yet  by offering him options that had virtually no curative or remissive power, he got the message that he could simply choose life over death. We knew that he did not want to die but we also knew that he was actively dying.   Continually providing him with empty choices felt wrong. Perhaps his denial of impending death helped him cope with the inevitable and if so, no problem. But, I have to question the prudence of allowing a dying patient in some degree of denial to be the sole or primary decision maker for his care. We want to do what you want John, even if we can’t deliver it.

In another family meeting, the sister of the dying patient, turned to the physician and asked, “Is my brother dying?”  As I sat on the couch watching, I said “Yes”, but to my surprise the team waited to hear that the sister thought he was dying, before they reluctantly agreed.  Don’t families who ask direct questions, want honest answers? What would have been so terrible about saying yes, straight away and adding “and this is what we think we should do now”.

A few times during the program we heard “there is nothing more that we can do” .Why would anyone say that?   “We cannot cure his cancer, but there is a lot we can do. We CAN, keep him comfortable, clean, talk to him, etc…..” that’s what I want to hear.

The severely demented, elderly mother whose family chose a respirator on which she has been reported to be dependent for over a my neck of the woods, she would have been transferred to a special nursing home that provided ventilator care and it would likely have been situated a good distance from her family. Maybe based on their religious beliefs or belief that mom is still aware, one could argue that this is a worthwhile endeavor. Rather than debate the value of any one life I do find myself asking if resources are limited, and millions are ineligible for medical treatment because they lack insurance, how do we justify the enormous spending on this one patient with a terrible prognosis?

Mt. Sinai has a superb palliative care service, yet this option was never fully utilized in the film. Social workers and ethics consultants were absent although my hope is that they were simply edited out. Important questions were raised by this program and the viewer certainly got a realistic front row seat of life in the ICU. It just struck me that we could do a lot better.

0 comments | Topics: Bioethics in the Media , End of Life Care , Patient Autonomy

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.