I could describe this patient a hundred times, and it would be at once a different person, and the same person. It's a situation I'm describing moreso than a person, what I am discovering is an archetype in health care: That Patient That Wants Everything.
A lot of the time, there's a point to doing everything possible. A lot of the time we catch someone in the middle of a bodily crisis, and we do everything we can to reverse this crisis, we intervene very aggressively and, for lack of a less dramatic term, we save their life.
Other times, however, the crisis itself is long past. Sometimes, there's no reversing the crisis. Sometimes, the situation is futile, and no amount of medical intervention will change that. Sometimes the only thing we can really do, medically, is relieve pain, and postpone the inevitable.
Some people want the inevitable postponed indefinitely, and this is when I get selfish. My coworkers appeal to my sense of grey in that spectrum of black-and-white, saying, "It's emotional. Those decisions don't get made based on logic. They have no concept of the kind of pain involved."
But it's exactly that pain that I'm fixated on. A man with a heart the size of a baseball glove, with lungs riddled with cancer tumors, receiving as much oxygen as I can give him non-invasively and still hypoxic, tells me he is short of breath. I know we can relieve this shortness of breath with opiates, using the euphoria of Mother Morphine to carry him away into his last goodbye. I've seen it done many, many times now. It's peaceful, looks comfortable from an objective standpoint, and to me, it feels humane.
But he doesn't want that. He wants everything. He's a "palliative" patient in that he wants relief of his suffering, in that he knows that there is no cure, but he's also a full code. "So he wants us to palliate him softly into the night, and then when his big floppy heart finally decides it's had enough, I'm supposed to stuff tubes in every orifice I can find, break his ribs, infuse him with enough adrenaline to wake the dead, and breathe for him with a ventilator? Until when, exactly? Until his heart finally dies?"
"Yes," she says, and proceeds to explain to me what this will mean for his family, for him emotionally, to know that we're not just simply going to let him die. She relates a story from when she worked for an oxygen vendor, where she regularly recommended the book Every Breath I Take to patients and their families. Then she would receive both ends of the extreme as to reactions: the end-stagers who get to the section on death and dying, and lament at their husbands, "Don't you let them do that to me!" And the other extreme, the family who would tear a big, meaty strip off of her: "Who do you think you are? How dare you?"
Why do I want these people to die? I don't so much want them to die. More, I hate watching them struggle to not die. I hate struggling to keep them alive, painfully, with much blood and vomit and broken bones, knowing full well that all the Levophed in the world won't make their cancer go away. I hate walking out of a room after a 'successful' resuscitation, covered in sweat and filled with frustration, knowing that it is now my responsibility to keep this person alive on the ventilator for another couple of weeks until some stroke of macabre luck ends his life just as swiftly as it began.
I won't change them, and my frustration and passion and wailing behind closed doors about "what do they expect?!" won't affect the outcome, for better or worse. Really, everyone else standing around me is thinking the same thing: we are all hoping in our heart of hearts that this time, just this once, the adrenaline and shocking and CPR doesn't work.
And that's why I say I'm selfish. Because I'm not thinking about the patient's fear of death, of their mental status worrying that they're being left to die, of the very pregnant silence that exists alone in a room where you've been put to die, knowing full well that you're simply waiting for it to happen, that you won't see the outside again until they wheel you from the morgue to the funeral home minivan.
Instead, I'm thinking of my sweat and sore muscles, my frustration at being backed between a rock and a hard place with regards to the ventilator, my exasperation at being forced to watch someone die slowly and painfully, rather than comfortably and peacefully. I could go on and on about how I'm thinking of what's best for the patient, how I'd rather they be comfortable and pain free, and it would be true. But if that isn't what the patient wants, then it's my own selfishness that makes me want it to be humane, that makes me hope I get backed into the impossible corner sooner rather than later, that makes me wish that at some point, their body would just give up already and take the ability to take action out of my hands.
Sometimes, I would rather be powerless. I would rather have no choices. I would rather we could be cold and distant, saying "there is nothing more we can do," for my own comfort. But it is wrong to take those choices away from people when it is their very own lives at stake. And so my comfort goes by the wayside, and I put on my serene face, and I hug, and I touch gently, when I'm not drawing blood or leaning on epiglottis or causing ventilator-induced lung injury.
I comfort them, but I wonder if it's really them I'm comforting, or myself.