We will all die, but the trajectory of our death will follow one of a few predictable patterns. According to statistics published in 2003 in the Journal of the American Medical Association, two-fifths of us will die with prolonged, dwindling illness on a slow downward slope typical of dementia or frailty. One-fifth will die with a sharp decline typical of, for example, metastatic cancer. Another fifth will die with intermittent dips, like a roller coaster, from heart or lung failure; and a small percent will die suddenly and unexpectedly, like falling off a cliff.
Nearly 80 percent of us want to die at home, polls have shown, but most die in the hospital, often strapped to a bed in the intensive care unit. And a recent study suggests that many people are subjected to surgery, even in the last week of their lives.
My experience tells me that whatever our trajectory, we are grossly ill-equipped to handle the dying process. Often I wonder how we — doctors, patients, the health-care system and society — can better prepare for death.
A few months ago, a patient of mine in his late 40s — a massively obese man, weighing more than 600 pounds — developed an overwhelming staph infection. As organ after organ failed and he became unresponsive, I convened a family meeting. In a conference room adjacent to the ICU, the nurse, my patient's close relatives and I sat on comfortable chairs with a lone box of tissues on a side table.
I always choose my words carefully during such conversations. When I see little hope of meaningful recovery, I focus on quality, not quantity, of life. I talk about the pain and suffering that can be caused by chest compressions if the heart stops or by a tube pushed down the throat if the lungs can’t pull a breath.
My tone and demeanor are distinctly different if I feel there is hope. When the wife of a middle-aged man who had been in and out of the ICU for six months met with me, she was very discouraged, but there was hope, so I talked about “continuing with the struggle” and outlined a recovery plan.
In the case of my obese patient, we decided to back off his quadruple-strength blood-pressure medicine and not put him on the ventilator. Yet I could not convince the daughter of the 84-year-old nursing home patient to take her mother off the ventilator and make her comfortable. Ultimately, it is the patient and family who decide how the end of life will come.