Questions of a disoriented third year medical student

“We talked about how we were the only two people in our family with any background in healthcare. I said to him, ‘In a little less than three years, I’ll be Dr. Cobb, how crazy is that?’ He looked up from his lost gaze and said ‘I hope I’m here to be able to call you that,’ and for the first time in my life I understood that he may not actually make it that long, that he was dying.”

I wrote that sentiment two years ago today and while my granddad never had the chance to call me Dr. Cobb, reading through these words today made me feel immensely better about his passing. A little over two months ago he died of respiratory failure after contracting pneumonia. I was studying for my board exam when my mom called me to let me know I should come into town. I packed up my things and was there with him and my family when he breathed some of his last breaths.

But what usually brings people peace, being there with a family member until the end, raised a lot of questions for me as a future healthcare provider. I knew he could have survived what he was going through. He could’ve had a tube stuck down his trachea, been put on a ventilator to pump his lungs for him; he could’ve been put on a feeding tube to maintain his weight; he could’ve been put on ECMO and had his blood pumped for him. At this time in medicine, we are really good at keeping the body alive, but not quite as good at keeping the person alive. In my granddad’s case, the person was all but gone long before those last days.

The question I’ve been tossing around a lot lately, and have already grappled with in one post, is when is treatment too much. But it becomes even more ambiguous than that. Morphine, for example, will lower respiratory drive, so in someone with respiratory failure who is extremely uncomfortable and likely going to pass, is treating their pain acceptable despite it accelerating death? Personally I think so, but the decision has to be made on whether you are treating pain or treating the illness, and that should be something the patient or the patient’s family has sorted out in advance.

Another question that stems off that one is at what point does the medication become treatment of symptoms with associated death-accelerating effects versus assisted suicide? Even if you disagree with assisted suicide, it’s hard to deny treating a miserable patient’s pain in the last moments of their life. Make them comfortable by all means. But if it accelerates death or even brings it on?

This last two weeks I worked on the pediatric hematology-oncology service and was faced with these questions in a different light. With a different age group, it frames similar situations in a completely different light. When these kids with cancer and blood disorders come in, we treat knowing the potential for so many more years of life that they have left to live. When you can treat, it seems like a miracle. But when you can’t, it elicits sadness and defeat on a scale I never could have imagined. It added complexity to the question, taking it from a geriatric population to a pediatric one: at what point do you stop treatment and simply comfort the patient.

I don’t really have answers to any of these questions right now, and I imagine if I expressed my opinions as a third year medical student just beginning to grapple with these questions, it would be only serve to show my naivete. I’m just understanding that all these dilemmas appear more simple when we are an outside observer but become so complicated when we see it in our own family or in our own patients. I’ll have to help families in similar situations in the future, and talk to families who ask me if there is anything that can be done. And in situations like with my granddad, I’ll know that there is, but that I cannot in good faith to my patient follow through with those treatments. I can’t imagine how I’ll fair, knowing that I stood there, watching my granddad, wishing the doctor would call for an intubation on my granddad, and then in the future be that doctor for someone else’s family. But I’ll have to, and I know it’s right. I need to look out for my patient.

4 thoughts on “Questions of a disoriented third year medical student”

  1. If discussions such as these occurred during a palliative medicine class, I think I might have kept my eyes opened the whole time. It’s been inspiring and thought-provoking to stand along side you while you processed some of these issues and I know that you are among the most patient-oriented future doctors out there! Keep honing this sensitivity of yours and don’t let the upcoming years harden you–we’ll need your sensitivity to serve as a constant reminder of why we chose this heart-wrenching vocation.

  2. One of my fall-backs is that families should treat their elderly relatives with as much compassion as they’d show their dog. When there’s more suffering than joy in their life and no way to remedy that, comfort care and, frankly, looking for any off-ramp is called for. Often that is morphine and letting pneumonia run its course.

    But what you’ll encounter in medical practice, to your frequent frustration, are adult children with (1) unresolved parent-child issues and (2) a tremendous fear of death. I wouldn’t want to be their dog and especially not their terminally ill parent.

    1. I’ve seen that a lot in the last few months and it’s really opened my eyes up to how much often we cling to our loved ones despite nearly absent quality of life. I just hope that when it becomes personal again that I am able to step back and make the right decision for my family members and able to counsel and be there for other families going through something similar. Thanks for your comments David.

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