Recently, I read “Final Exam: A Surgeon’s Reflections on Mortality” by Dr. Pauline W. Chen because I’m hoping to become a physician assistant and I want to devour as much information about working in the medical field as possible. I thought the book would be cool and interesting when I picked it up, but discovered a surgeon’s internal debate on ethics, death, and end of life care. This book has made me consider my work experiences in a new light. As a surgeon, Dr. Chen is given the role of lifesaver on a daily basis. Who better to discuss that delicate line between life and death, the line that is constantly being blurred by medical advances, machines, and drastic miracle surgeries? Honestly, this review has been hard to write. I have my own personal opinions based on things I’ve read about and witnessed, but there are many people out there I know are uncomfortable discussing death. Thinking about what I write from their perspective and the view of those who may have been in these situations before makes me question what I write, as I want to tread carefully. At the same time, though, I believe with all my heart that these conversations are important. Death, dying, and end of life care are tough subjects. Dr. Chen delicately broaches these topics but still writes honestly, something I can only aspire to. Here is my attempt to share my thoughts.
As a patient care technician on an oncology (along with other specialties) floor, I have had several opportunities to come in contact with patients with stage 4 cancers. I’ve seen patients who appear completely healthy and came in with constipation or rectal bleeding, only to find out their entire colon is covered in tumors, and they’ll need an ileostomy and aggressive chemo for any chance of survival. Patients come in all the time with seemingly benign symptoms actually being caused by the spray of cancerous cells growing throughout their bodies. In these cases, the obvious desire of many patients and their families is to fight the cancer with whatever means necessary. Upon learning of John McCain’s recent diagnosis, Americans released a tweetstorm of “you can beat this” and similar regards. We, as a country (I can’t speak for other countries/cultures) have an inherent fear of death and dying. There are articles and documentaries explaining how to prevent/fight/cure cancer, much of which is unproven, but that’s another topic. It is in cancer’s nature to replicate, to spread to every corner of the body it can wedge itself into, and at the present time, medicine hasn’t advanced far enough to win most of those battles. We must still catch it early for patients to have a good chance of survival. Some patients will opt for only comfort care, they will choose to enjoy what life they have left and go when the cancer has taken its toll. Some will decide to fight until the very end, undergoing countless excruciating surgeries and treatments, which may or may not prolong their life. This is true with other potentially terminal illnesses and traumas as well. For children, who are incredibly resilient, or healthy individuals, treatments may be effective and provide years of life that patient may not have otherwise had. But for 92 year old grandma with dementia and brittle bones whose family insists on all possible measures and a full code if necessary, sometimes the treatment is worse than the disease, and the patient may not get more meaningful years out of it. It is my opinion, and some may disagree, that six more months of life hooked up to tubes and a ventilator in which the patient may not even be aware of people around them isn’t the best option. If a disease or condition is going to kill a patient anyway, is there a point to every procedure and treatment option? If I were an elderly lady lying in the hospital dying of cancer that has spread to my lungs and bones, which procedures would I want? I’d turn down chemo if doctors don’t believe it has a great chance of helping me. Maybe I’d opt for surgery if removing a tumor would make me significantly more comfortable, such as one that’s pressing on my trachea and making it difficult to breathe. If I knew the cancer was terminal, I probably wouldn’t want doctors running a painful full code on me, I’d rather die in minimal pain, with my loved ones by my side.
This is what I believe Dr. Chen is getting at in her book. I’ve witnessed what happens during a code. It is messy. Ribs crack during chest compressions, tubes are shoved down the patient’s throat, they are poked and prodded and pumped full of drugs, they may be shocked. If the patient survives all of this and a pulse returns, then they are subject to more tests to figure out what went wrong, and may remain intubated and hooked up to a ventilator. Even then, they still may not survive. Now, personally at this stage in my life, if I go into the hospital, I want to be a full code. I want life saving measures, as long as doctors believe there is a chance I can be saved. But, as Dr. Chen realized throughout her narrative, there are times during which palliative or comfort care measures are more appropriate. Sometimes, patients want to die in the comfort of their own home, surrounded by family receiving only medications which will decrease pain, not prolong their life. As healthcare providers or future healthcare providers, we can do a great deal to help these patients and their families through these types of decisions. Families are likely to feel guilt that they are “giving up” on their loved one, they feel grief, anger, devastation, regret, but we can be there to support them.
I think that Dr. Chen makes great points about how medical professionals need to be made more comfortable with this type of care. There isn’t always a medical or surgical solution for someone’s health issues, but death is such a taboo that many find it difficult to even think about. Many people have no advance directives in place, so their families are left to make decisions for them in their emotional state. I haven’t had to make those decisions, thankfully, but I truly believe that anyone who is that distressed will have a hard time thinking rationally and making the choice that is best for the patient and what the patient would really want. It’s so important to have honest discussions with our patients and our own families about these topics, and I think Dr. Chen’s book is a great place to start. I would highly recommend “Final Exam: A Surgeon’s Reflections on Mortality” by Dr. Pauline W. Chen to anyone considering a career in the medical field or to anyone interested in end of life care. I’d love to talk with any of you about this book, medicine, any other books, or life if you want, so feel free to get in touch!!