Carrie Fisher died today. My children received this news as a tragic loss. I received it with relative indifference, not toward Fisher, but toward the outcome. Fisher is an example (at least insofar as we have public information) of futile care. There are many such examples, and their contrast with physician death is revealing.
Carrie Fisher had, depending on your source, a 'cardiac event', a heart attack, a cardiac arrest, or a respiratory arrest while on an aircraft. There is no requirement for a pilot to deviate from a flight plan for a medical emergency, and Fisher's care was, at least as described, entirely appropriate for the setting, administered by two medical professionals who were on board. She received CPR for roughly an hour on the aircraft, and upon landing immediately received Advanced Life Saving techniques. She was brought to an ICU, where she was reported as 'stable'.
For those who do this kind of work, we knew Carrie Fisher was dead, or at least functionally so, or brain dead. The likelihood of surviving one hour of CPR neurologically intact approaches zero. When she was reported as stable in the ICU for two days, I and every MD knew she was brain dead. That is a stable condition, just stable and very, very bad. I imagine that, after confirmation of brain death, life support measures were stopped, and she died.
Similar situations have produced similar amounts of public angst. Gilda Radner's death 30 years ago is one. She had a stage 3C ovarian cancer. Initial surgical debulking was not optimal. Her chemotherapy had to be shortened because of low white cell counts. Her second look surgery was, predictably, positive. She was dead 18 months from the initial diagnosis. This prompted her memoir 'It's Always Something', which reflects rather bitterly on her impending death. Her survival, however, was strictly average for a person with her stage and type of tumor.
Every physician knows these stories. We have performed, or participated in, futile care. CPR where ribs break without any hope of revival, surgeries and debilitating chemo for clearly fatal tumors. Yet, we give little honest counseling about end-of-life decisions, and too many people, influenced by news reports of miraculous survivals, or by TV dramas, elect to pursue care we know has a low chance of success at high cost in money and incapacitation.
Physicians don't do this. We are more likely to die at home, or in hospice, rather than in hospital or especially in an ICU. We have seen the results of our terrible treatments- baldness, nausea, weight loss, incapacitation, weakness, loss of appetite, sexuallity, mobility. In short, loss of humanity. We choose not to participate in the pointless end-of-life care that others describe as heroic. To paraphrase James Bond, you should hope that you die in your chair before allowing yourself to be subjected to this kind of treatment.
The only universal in life is death. Even taxes are not inevitable. You can go to prison, be fined and fail to pay it, engage in illegal cash-only businesses like drug dealing or prostitution, fail to report tips. But no matter how you live, you are going to die. MDs are too often caught up in their technical knowledge and expertise, or are afraid to have an honest discussion with a patient, to have an honest conversation about end-of-life care.
Carrie Fisher's death is sad, and a loss, but it was not surprising. Barring a literal miracle, Fisher was dead when she came into the ICU, every bit as much as when she left it. We could not have helped her death, but we can help its manner, by giving proper, honest counseling to those who depend upon us.
Ted
Carrie Fisher had, depending on your source, a 'cardiac event', a heart attack, a cardiac arrest, or a respiratory arrest while on an aircraft. There is no requirement for a pilot to deviate from a flight plan for a medical emergency, and Fisher's care was, at least as described, entirely appropriate for the setting, administered by two medical professionals who were on board. She received CPR for roughly an hour on the aircraft, and upon landing immediately received Advanced Life Saving techniques. She was brought to an ICU, where she was reported as 'stable'.
For those who do this kind of work, we knew Carrie Fisher was dead, or at least functionally so, or brain dead. The likelihood of surviving one hour of CPR neurologically intact approaches zero. When she was reported as stable in the ICU for two days, I and every MD knew she was brain dead. That is a stable condition, just stable and very, very bad. I imagine that, after confirmation of brain death, life support measures were stopped, and she died.
Similar situations have produced similar amounts of public angst. Gilda Radner's death 30 years ago is one. She had a stage 3C ovarian cancer. Initial surgical debulking was not optimal. Her chemotherapy had to be shortened because of low white cell counts. Her second look surgery was, predictably, positive. She was dead 18 months from the initial diagnosis. This prompted her memoir 'It's Always Something', which reflects rather bitterly on her impending death. Her survival, however, was strictly average for a person with her stage and type of tumor.
Every physician knows these stories. We have performed, or participated in, futile care. CPR where ribs break without any hope of revival, surgeries and debilitating chemo for clearly fatal tumors. Yet, we give little honest counseling about end-of-life decisions, and too many people, influenced by news reports of miraculous survivals, or by TV dramas, elect to pursue care we know has a low chance of success at high cost in money and incapacitation.
Physicians don't do this. We are more likely to die at home, or in hospice, rather than in hospital or especially in an ICU. We have seen the results of our terrible treatments- baldness, nausea, weight loss, incapacitation, weakness, loss of appetite, sexuallity, mobility. In short, loss of humanity. We choose not to participate in the pointless end-of-life care that others describe as heroic. To paraphrase James Bond, you should hope that you die in your chair before allowing yourself to be subjected to this kind of treatment.
The only universal in life is death. Even taxes are not inevitable. You can go to prison, be fined and fail to pay it, engage in illegal cash-only businesses like drug dealing or prostitution, fail to report tips. But no matter how you live, you are going to die. MDs are too often caught up in their technical knowledge and expertise, or are afraid to have an honest discussion with a patient, to have an honest conversation about end-of-life care.
Carrie Fisher's death is sad, and a loss, but it was not surprising. Barring a literal miracle, Fisher was dead when she came into the ICU, every bit as much as when she left it. We could not have helped her death, but we can help its manner, by giving proper, honest counseling to those who depend upon us.
Ted
Comments
Post a Comment