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On Being a Doctor |

A Party Before Dying

Chris Sankey, MD
[+] Article and Author Information

From Yale-New Haven Hospital, New Haven, CT 06510.


Requests for Single Reprints: Chris Sankey, MD, Yale-New Haven Hospital, 20 York Street, CB2041, New Haven, CT 06510; e-mail, christopher.sankey@ynhh.org.


Ann Intern Med. 2010;152(6):402. doi:10.7326/0003-4819-152-6-201003160-00014
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I met Joe the way I meet all of my patients: His name appeared on my daily hospitalist list. He was an intensive care unit transfer, recovering from hypercarbic respiratory failure related to chronic obstructive pulmonary disease, congestive heart failure, and deconditioning after recent aortic valve surgery.

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Wrong message to physicians and students
Posted on April 7, 2010
Kenneth L. Cohen
No Affiliation
Conflict of Interest: None Declared

Except for the two states in which euthanasia is legal (Oregon and Washington) I was appalled to see how Dr. Sankey helped Joe go (1). If the information is as indicated (Joe was given a morphine drip to ensure his demise after his party) this certainly would meet my definition of euthanasia even more so than what Dr. Kevorkian was sent to prison for. In the Kevorkian cases the patients clearly requested assistance in dying and even though Joe was "ready to go," I see no indication that he requested euthanasia. Joe was clearly dying as so many of our older patients are, but regardless of our feelings, this method is clearly illegal in Connecticut and 47 other states although it resurrects many ethical and moral controversies.

I also regret that Joe's story allowed the author to feel more like a doctor than he ever had before. Hopefully most of us feel like doctors by providing kind and compassionate care in a host of other situations.

Finally, if the Editors endorse this action I believe it regretfully sends the wrong message to young physicians and students.

Reference

1. Sankey, CH. "A Party Before Dying." Ann Intern Med, 2010:152;402.

Conflict of Interest:

None declared

Ed Taught Us How to Die
Posted on May 3, 2010
Paul Sacks
Arizona Kidney Disease and Hypertension Center
Conflict of Interest: None Declared

TO THE EDITOR: I just read with bittersweetness the story by Chris Sankey, "A Party Before Dying" (1). It brought back to my memory the story of my good friend and collegue, Ed. Ed had trained as a mechanical engineer in Louisville, Kentucky. After several interminable years sitting behind a desk, he entered medical school and subsequently completed a residency in internal medicine. He then moved to Arizona where he joined an internal medicine practice and later became a hospitalist at the hospital where I work. Ed took to medicine as a passion working countless hours to ensure the wellbeing of his patients. Ed and I became close friends occasionally getting together for dinner or a movie after a long day at the hospital.

Five years ago, he developed abdominal pain. He went down to the radiology department and ordered a CT Scan of his abdomen which confirmed pancreatic cancer. He was only 48 years old but he knew in the radiology viewing room that evening that his life expectancy was going to be very limited. He immediately retired from his practice and began producing tile mosaic pieces for his friends. He took himself off the diet that he had been on for years. He began to spend more time with his family. He started the obligatory chemotherapy for palliation.

But what he did next was what this story brought to mind. He and his wife, Janet, decided to have a Kentucky Derby Party. We were all surprised by this move but excited to be able to participate in this passage in Ed's life. His wife prepared Mint Juleps and a burgoo stew. There were numerous bourbon laden desserts as well. We all received Kentucky Derby drinking glasses as souvenirs. Most importantly, the mood was upbeat and joyous. For this day, we all smiled with Ed.

A few short months later, Ed died as expected. The hospital held a memorial service for him at which several of his collegues spoke. One of the senior members of the medical staff put it succintly when he said, "Ed taught us how to die".

References

1. Sankey, C. A Party Before Dying. Ann Intern Med. 2010; 152: 402.

Conflict of Interest:

None declared

Re: Wrong message to physicians and students - Part 1
Posted on August 15, 2010
Chris Sankey
Yale-New Haven Hospital
Conflict of Interest: None Declared

I was disheartened to see Dr. Cohen's response to my story "A Party Before Dying" (1). His accusation of euthanasia is serious, so please allow me to set the record straight: Joe died of respiratory failure, and Dr. Cohen's discomfort with the circumstances of his death does not make it criminal or even ethically questionable. In the days before his death, Joe's respiratory failure -- a product of severe underlying COPD, refractory congestive heart failure, recurrent nosocomial aspiration pneumonia, respiratory muscle weakness, and malnutrition -- required continuous BiPAP to mitigate hypercarbia and allow him to maintain an interactive mental status. The BiPAP mask was beginning to cause pressure sores on his face and nose. He was offered repeat intubation with subsequent tracheostomy (he had been intubated three previous times during his hospitalization) and percutaneous gastrostomy, options he emphatically refused. Joe declined all life-sustaining intervention; as such, death was imminent and discussions regarding end-of-life care were appropriate.

After cessation of BiPAP, death was felt likely to occur rapidly enough that transfer home for hospice or to an inpatient hospice facility would not be possible, an assumption that is supported in the literature (2). In lieu of going home, all Joe wanted was a meal with his family, with the venue and means by which this occurred being the substance of my original writing. He was not allowed nutrition by mouth due to concerns of recurrent aspiration -- his eating during the party and the removal of the BiPAP mask to do so were both clearly explained to him as actions that would bring about his proximate demise. He understood, and with the support of his family, wished to proceed. The agreement between Joe, his family, and his caregivers prior to his "party" was that BiPAP would not be resumed thereafter; hence, its discontinuation was tantamount to a terminal extubation. His progressive respiratory failure was treated with oxygen and morphine, as is common practice in end-of-life care and consistent with practice guidelines published in this very journal (3). He did not ask for, nor did he receive euthanasia by any stretch of the imagination.

References

1. Sankey, C. A Party Before Dying. Ann Intern Med 2010;152:402

2. Cooke, CR et al. Predictors of Time to Death After Terminal Withdrawal of Mechanical Ventilation in the ICU. Chest 2010;138(2):289- 297

3. Qaseem, A et al. Evidence-Based Interventions to Improve the Palliative Care of Pain, Dyspnea, and Depression at the End of Life: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med 2008;148:141-146

Conflict of Interest:

None declared

Re: Wrong message to physicians and students - Part 2
Posted on August 15, 2010
Chris Sankey
Yale-New Haven Hospital
Conflict of Interest: None Declared

Dr. Cohen's reply represents the unfortunate persistence of an entrenched view that physicians who support and actively participate in the administration of palliative care are "renegades," with careless and damaging comparisons to Jack Kevorkian. The right of patients in all states to forego life-sustaining interventions has been well established, and most deaths in this country now occur after decisions to withhold life support (4). It is thus incumbent upon us as physicians to plan for such scenarios and to aggressively manage the symptoms associated with the dying process. Evidence suggests that narcotics and benzodiazepines, when given after the withdrawal of life support, do not in fact hasten the time to death (5); belief to the contrary can lead to inappropriate withholding or under-dosing of these medications when they are most necessary. Unfortunately misconceptions continue to result in patients receiving insufficient symptom management prior to death, with commensurate distress among families and caregivers. Furthermore, the assertion that physicians do not have permission to gain satisfaction from the doctor-patient relationship in the palliative care setting is upsetting and fundamentally incorrect.

I am disappointed above all that Dr. Cohen clearly missed the point of the story. How many patients actively dying in the hospital are granted their last wish of enjoying a meal with their family in the way Joe was able? A minority, according to a study finding only about a third of nurses rate the quality of death and dying in the hospital as suitable for themselves (6). The addition of non-pharmacologic means to the palliative care armamentarium, this kind of 'party' included, is something about which I strongly believe physicians and students should be educated.

The decisions regarding the circumstances of Joe's death were the culmination of my four week relationship with a patient, his wife, and his three sons. If this kind of patient- and family-centered (7) end-of-life care is not a positive message for students and other physicians, I am in need of re-education as to what is.

References

4. Pendergast, TJ et al. A National Survey of End-of-life Care for Critically Ill Patients. Am J Respir Crit Care Med 1998;158:1163-1167

5. Chan, JD et al. Narcotic and Benzodiazepine Use After Withdrawal of Life Support. Chest 2004; 126:286-293

6. Ferrand, E et al. Circumstances of Death in Hospitalized Patients and Nurses' Perceptions. Arch Intern Med 2008;168(8):867-875

7. Henneman, EA and Cardin, S. Family-Centered Critical Care: A Practical Approach to Making It Happen. Crit Care Nurse 2002;22(6):12-19

Conflict of Interest:

None declared

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