End-of-life ethics.

Today's ethics topic was a good one, although the lecture/panel discussion was poorly run and some of my classmates made rather astounding comments during the small group section.

The discussion was about a terminal cancer patient who wished to continue to receive aggressive treatment even when it was clear that she was not going to get well, and was probably going to die within the next six months. Her reasons for requesting continued treatment were ambiguous; the oncologist reported that she claimed to be "waiting for a miracle." At any rate, the treatment was continued at her request and she repeatedly refused to consider entering hospice care or even take any pain medication. Predictably, she became sicker and was moved to the ICU. At some point she became unable to make medical decisions and in spite of her previous request to "keep doing everything," her family requested that all life-sustaining measures be discontinued; she died shortly thereafter.

Now, the case was presently badly and the physicians failed to address some of the concerns which any first-year medical student could see coming a mile away (Why wasn't an ethics consult requested? Doesn't continuing treatments that have no chance of working send a mixed message?), but I found some of my classmates' comments needlessly hostile toward the physicians. One peer criticized the physicians for judging the woman based upon her religious convictions. Another student suggested that the physicians blamed the patient for putting them in an uncomfortable situation. I didn't hear anything quite so clear-cut during the discussion; what I inferred was that the physicians were incredibly frustrated with this woman, and were uncomfortable with continuing aggressive therapy, but did so anyway because it was what the patient wanted.

I find it a bit unsettling that my classmates are so quick to express strong opinions regarding a situation which was obviously very complicated and not easily resolved. It is presumptuous to assume that facing a similar situation, we would not follow the exact same path, or would even have much choice in the matter. Hindsight is 20/20; it is easy to argue anything from a philosophical or ethical standpoint, but it can be very difficult or impossible to implement those ideals into a real clinical situation, particularly if the doctor and patient have completely different opinions on the appropriate course of action. Assuming that the patent was made clearly aware of her prognosis, what choice did the doctors have but to keep treating her? They might have simply told her that there was nothing more they could do and shoved her out the door, but with no hospice care plan in place, that would have been tantamount to patient abandonment. The situation might have been ameliorated if other hospital personnel had been involved, but it seems unlikely that the patient would suddenly have had a change of heart and agreed to stop treatment. The only other recourse is the legal avenue, and I imagine that the doctors wanted to avoid dragging an extremely ill patient into a bitter legal battle to have her declared incompetent to make decisions.

It was undoubtedly a sad case, and I have no doubt that the physicians were extremely torn on what was the "right" thing to do for this woman. Sometimes there are no easy answers, and my classmates would be better served by thinking more deeply into these ethical problems than they currently are inclined.