Medical ethics on limited options
Posted by The J Train
I really didn't offer up much of an introduction in my previous post. I'm an internist (which, I tell those who ask, is like being a pediatrician, but for adults) fresh out of residency and starting up in private practice in eastern Kentucky. I have been writing on the internet for a very small audience for some time, starting with my eponymous web site (now on "indefinite standby") and a blog called The Internal Monologue (now defunct), and more recently on my LiveJournal (now Friends Only).
Amanda Marcotte links to this story about some doctors in New Orleans who had to get their hospital evacuated, but who had terminally ill patients who were too sick to survive the trip. Rather than leave them to die alone, they gave the patients big enough pushes of morphine to end their lives before everybody got out. I don't know how reliable it is, but it's absolutely plausible (that is, I'd be shocked if this didn't happen somewhere in all this).
"Triage", as the word root implies, originally meant separating patients into three groups--those who would likely be OK without medical care, those who are beyond any help, and those who can benefit from medical care. The idea is to concentrate resources where they can do the most good; it's no use spending valuable time working on someone with hours left to live no matter what when you can save decades of meaningful life for three or four other people in the same time. In that case, the right thing to do is to provide comfort for the dying, and in a serious and urgent situation, that might include active euthanasia.
This is not hard to justify once you accept the fact that some patients are going to die in the short term, despite anything anyone can do. A lot of people don't accept that; they believe that one should never give up hope, and that death should be fought until the last dying breath. We doctors often encourage that attitude, because somewhere along the way, we decided that it was healthier for patients and families to plan on a miracle than to prepare themselves for the inevitable. The hospice movement has helped us get a lot better about that in the last couple of decades, but it's still pretty common for doctors to tell patients and families not to give up hope when the prognosis is long since clear.
I can see the patients they're talking about--probably the ones already requiring large doses of morphine for comfort care, so they're not responsive or interactive. Their families, previously by their sides as much as possible, are (reluctantly) long gone. (The tone of the article, plus the fact that every hospital in America has several of these patients, leads me to think this is who they're talking about.) If the hospital absolutely has to get cleared out, there are only three options:
--Evacuate the patients. It may not even be an option. If it is, they'll probably die en route. If they do make it, it's just so that they can wait to die in a different building, probably still separated from family, and (just to be frank about it) using resources and manpower that are already scarce to delay the inevitable for a little bit. The patients' last hours will be spent in a flurry of activity, and on the other end comfort will almost certainly take a back seat to raw necessity.
--Leave the patients. They won't make it, but the lack of nursing care or meds will mean their last hours will be spent alone and miserable. This is not an option, IMO.
--Push the morphine.
From a strictly utilitarian standpoint, there is only one good option, and a disaster like Katrina brings out the utilitarian in all of us. That doesn't make it easy to do, or easy to accept.