Death Panels: Really? I don’t think so…

“I don’t know what to call it, it’s hard- bad either way, it’s not a panel, not a death panel, it’s just a hard decision: she dies today if we operate or she dies later if we don’t.”  Anesthesia

Gavel

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It was an odd start to the day.

A pretty tough case coming up, a double valve on a 50ish year old patient, and they were as sick as advertised.

There were a few hemodynamic issues that needed to be looked at prior to proceeding with what was going to be a hit-or-miss proposition in terms of the long term prognosis for the soul in front of us.  In this case some hard decisions needed to be made prior to engaging further, and it is moments like these that physicians definitely earn their pay and status,

Pulmonary hypertension if not reversible, sets you up for a longer sequence of incongruous possibilities as more often than not, coronary bypasses and valve repairs/replacements may represent a minor patch for a condition that requires a possible heart transplant, and in the case of irreversible pulmonary hypertension, suggests the need for a combination of both heart and lung transplants.

You Qualify:  That’s if you are otherwise healthy (absent organ failure of other systems).

That was not the case here, so we have a full crew, and a worried surgeon, and everybody understands that neither choice will be easy for the team or the patient.

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Adding to that was an amazing sequence of events

… as the patient was transferred from the gurney to the OR table.  She looked at all of us, and hers was a face that was serious and resolute, yet full of warmth and humanity.  What I saw was bravery, and what followed was a departure from the typical structured OR sequence, as she simply smiled and invited us all to come together in prayer for what was now to be a joined circle of friends- not strangers, as she spoke of  strength and steadiness in our hearts and in our hands.

As she said that prayer, she was slowly being induced under general anesthesia, and we all held hands, and my phone went off, with of all things, the I-phone ring tone of “harps”  that I have set to my wife’s number so that I know whenever she calls me- that it is her.  So it was an “angels in the back ground” whisper that we all heard as she fell asleep.  How odd, and it was nothing I could ignore because I just don’t believe that in such moments, whatever God you divine to- is absent.

As the last words of the prayer fell from her lips, our patient fell asleep, as if choreographed for a scene in a movie.

Yeah…  I dropped a tear- and shared that fact with the people I work with- my best friends aside from my family.

And then the conversation started as anesthesia stress-tested the patient to determine exactly, the limits of her pulmonary capacity to get a clearer idea of her ability to survive not only the operation, but to live past recovery and leave the hospital alive as well.

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Call it what you want…

You can call it a checklist.

You can call it an assessment.

You can call it a consensus of medical opinion.

You can call it mercy, or merciless.

You can call it calculated.

You can call it clinical.

But you can’t call it a “Death Panel”

That term is for the idiots of the world.  Reserved for the uninformed, the self serving, and the clueless narcissists who have never witnessed the process of saving lives or caring for the infirm.  People that don’t see or know death, condemn it, hide from it, and misunderstand it.  These are people that have not the education or common touch to discern from their own self absorbed fabric, the countless variables that go into every decision on whether to render care or not to.

What you can call it is a very hard decision, unencumbered with politics, insurance issues, or conservation of medical resources.  What you can call it is a team of very fine men and women, highly trained, ready to deliver and perform, that are asked to stand down, not due to anything but the gut wrenching reality that in the long run- some things will not be survivable.

And this was not a casual, poorly thought out decision.  The signature had the backing of highly trained surgeons, a Military man, and a Harvard man, and an amazing anesthesiologist, with a combined 60 to 100 years of solid clinical decision making, coming together to decide to do what they hate to do the most- let nature be, and not to operate.

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It becomes a dance- that the rest of us watch…

No doctor wants to pronounce prematurely that they can’t operate or save a patient.  Especially when they are in your operating room, and anesthetized.

No anesthesiologist puts a patient “under” if there is a question of the operation commencing, or the outcome is pronounced uncertain (assuming it is a non-emergency).

In this particular case, the case was scheduled, with the understanding that an evaluation that could only be made under general anesthesia, would determine the course of events on whether or not to proceed or cancel.

And so it went.  And preliminary findings sucked.  And all continuing efforts to find anything more complimentary to potential survival were equally rebuffed.

So the bartering begins.  The surgeon expresses hesitation and enumerates the potential pitfalls, anesthesia responds and expresses the obvious end result of NOT operating, and continues to look for hope.  The surgeon takes leave, to sort things out and leaves his colleague to assess the patient at his own pace with no external pressure.  An opportunity for both to find an answer unencumbered with peer or external pressures.

It takes an hour to decide a life…

and the two come together, joined by a third opinion, and that finally becomes that.

Stated aptly and haltingly during the process were the words of a gifted man, someone I respect for their dedication to medicine, humanity, and medical missions, was an admission of the weight of the responsibility that comes with being a Doctor of Medicine.  I asked him about how hard it was and the ramifications of the situation- (we are friends from living through and salvaging many tough cases).

His response:

“I don’t know what to call it, it’s hard- bad either way, it’s not a panel, not a death panel, it’s just a hard decision: she dies today if we operate or she dies later if we don’t.”

And then he went back to work, trying to find an answer that wasn’t going to be.

Case: CANCELLED

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