On Limiting Treatment and Being "Pro-life"
Mr. V's chest pain had ceased several hours before he arrived at the emergency department. He described three days of pain that sounded very suspicious for myocardial infarction, complete with some diaphoresis. His cardiogram was also suspicious for acute infarction. His CPK (enzyme test for a heart attack) was normal. Was he already past the CPK peak, or had it not yet risen? We won't know, because he went back home. Even after careful explanation of what was suspected and the danger of it, he persisted in his request. His daughter was present and was obviously skeptical of his plan. The two of us could have prevailed upon him and almost certainly won him over to a coronary care unit admission. I have done such persuading often enough before.
This time, however, I "took his side." After length discussion with him, his daughter, grown granddaughter and wife he went back home. To this writing a few days later, he has survived and remained comfortable. Maybe he didn't have an infarction, but sending him home was unorthodox, at least by local medical standards. I believe I could convince most area practitioners that the action was reasonable, even if it were not something they themselves would do. But there is another group which would probably be highly critical of such an action - some of the pro-life groups who are struggling against euthanasia. Since I have read some of their attacks against medical practices which resemble this one of mine, let me imagine their response to my action and attempt an explanation to these with whom I share so much in common.
One charge is that I failed to avail him of all that is possible to preserve his life. I plead guilty if the word "intended" is substituted for "possible." The actual effect of CCU admissions on preserving life is much more questionable than the intentions. The literature on the effectiveness of CCU admissions in situations resembling his reveals that the evidence proving CCU effectiveness is vaporously thin. At times we may congratulate ourselves on the wisdom of CCU admission when a patient is brought through a dangerous arrhythmia and fail to consider whether the adrenochromes induced by the stress of the CCU environment contributed to the arrhythmia. My intentions were the same for him as for all the others whom I have admitted to the CCU. The CCU just didn't seem to offer much in the way of possibilities for life in his case.
Since Mr. V is 81 years old, I could be charged with discrimination based on age. Again, I plead guilty to discrimination, but innocent on the grounds that it is reasonable to discriminate between someone who is in his condition end someone who is not. If Mr. V were in the best of health, his average remaining life expectancy would be only about 7 years. He is not in the best of health. He has been surgically "whittled away" in the past 4 years as the same sort of vascular disease which affects his heart took his legs in three separate operations. He has chronic lung disease, diabetes, paralysis in one arm and inability to swallow due to prior strokes. He is fed through a gastrostomy tube. His kidney function is poor as is his vision. I doubt he will survive two more years no matter what is done.
Certainly a year in your early 80's is as previous as one in your 20's. But six months undergoing the rigors of modern hospitalizations represents a sizable portion of your remaining life at 80, only a small fraction at 20. If every available technology must be used until death, then we must push past gastrostomy tubes to respirators, organ transplantation, heartlung machines, and whatever other technique comes down the pike. Otherwise, some criteria must be used to decide when not to "do everything, " and the patient's general condition and desires in the matter certainly are near the top of the list of possible criteria.
Another possible charge is that I am contributing to the decline of medicine down a slipper slop to euthanasia. Not guilty. The slope gets slippery when I tread on God's prerogatives. Death is His prerogative. The maintenance of physical life, as high a priority as it is, is clearly not His highest prerogative. It is He who pronounced the curse of physical and spiritual death upon our race in Eden. He has sent out armies to kill (not murder) enemies. He established capital punishment. No technology can finally overcome the curse of disease and death. If we use our own resources or those of others to prolong physical life in any and every situation, no matter what, we have made physical life our highest value. As such it is an idol, for only the sacrifice of Jesus Christ makes possible our final freedom from physical and spiritual death.
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