Freedom from the Tyranny of Choice — Teaching the End-of-Life Conversation — NEJM

Freedom from the Tyranny of Choice — Teaching the End-of-Life Conversation — NEJM

Thirty years ago, an intern had a conversation with a patient that he regrets to this day. The patient, a young man with widely metastatic lymphoma, unresponsive to chemotherapy, now had progressive dyspnea. The intern knew that even with intubation, his patient would soon die. Although the norm at that time was for physicians, including house staff, to make end-of-life decisions without involving the patient, the medical team, struck by the patient's youth, asked the intern to elicit his wishes. Uncertain and frightened, the patient said, “I want everything.” Intubation followed, and then multiorgan system failure; the patient died on the ventilator weeks later, never getting an opportunity to say goodbye to those he loved.




More recently, another resident made a decision he feared he would regret. A woman in her 30s with widely metastatic breast cancer presented with shortness of breath resulting from bilateral malignant effusions. The resident's job was to triage the patient to the appropriate level of care. Although her cancer had been diagnosed a decade earlier, no physician had discussed her end-of-life wishes. In the middle of the night, the patient was in respiratory extremis; intubation was imminent if her life was to be prolonged. The resident decided to make it clear to the patient that she was dying. Comfort measures were initiated. The resident feared he'd overstepped his bounds and that the patient's oncologist would be angry. Instead, when the patient died peacefully 3 days later, the oncologist and the family all expressed their gratitude.

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This is such an important duty not to be neglected.