A harder death for people with intellectual disabilities

Several weeks after my patient was admitted to the intensive care unit for pneumonia and other problems, a clear plastic tube sprouted up from the mechanical ventilator, onto his pillow and down into his trachea. He showed few signs of improvement. In fact, the weeks on his back in an I.C.U. bed were making my 59-year-old patient more and more debilitated.

Still worse, a law meant to protect him was probably making him suffer more.

When the prognosis looks this bad, clinicians typically ask the patient what kind of care they want. Should we push for a miracle or focus on comfort? When patients cannot speak for themselves, we ask the same questions of a loved one or a legal guardian. This helps us avoid giving unwanted care that isn’t likely to heal the patient.

This patient was different. Because he was born with a severe intellectual disability, the law made it much harder for him to avoid unwanted care.

To learn more, including what happened, read my new post here at The New York Times.

Giving patients what they want, even if the doctor doesn't have the time

Doctors struggle to find the time to have in-depth conversations with their patients. Patients, in turn, don't share their end-of-life preferences with their doctors, which leaves them vulnerable to getting more aggressive care than they want. It also wastes a huge amount of money. 

In my new article, I confess a time I contributed to this problem, and point to a really exciting new solution. Harvard researchers, conducting a huge study across the state of Hawaii, have now proven a new way patients can get their wishes respected even if their doctor doesn't have as much time as they want. Online videos about end of life decisions. The videos are outstanding, and proven to work. Plus - bonus! - they saved the system money. 

It's win-win. Check it out!

Why it's getting harder to know if someone is dying

We tried our best, but CPR, an injection of epinephrine, and 360 joules of electricity all failed to restart Mrs. Melnyk’s heart. When everybody on the resuscitation team agreed that we could do no more, I said the words: 

“Time of death, 9:32.”

As we cleaned up, a young nurse began to tuck a clean white sheet around Mrs. Melnyk’s body—and then suddenly stopped. 

“Wait!” she shouted, pointing at the heart monitor. There on the screen, an electrical impulse registered and quickly disappeared, replaced by a flat green line. “It’s too soon to give up!” the nurse said. 

It turned out the young nurse had been fooled by a stray electrical discharge on an EKG machine. Together with her supervisor, we talked it through, and did not prolong the code blue.

That kind of confusion is getting more difficult to clear up, though. With newer technologies like PET scans and ECMO, the dividing line between life and death is getting harder to define. 

To read more, check out my new post in The Atlantic. 

Doctors Should Not Deny Ebola Patients CPR

The first time I did CPR, coagulated blood spurted onto my new white coat from a wound in the patient’s chest. Another time a patient’s urine soaked through the knees of my pants as I knelt at his side.

Even in the best of conditions, cardiopulmonary resuscitation (CPR) is a spit-smeared, bloody business that can expose health care workers to all kinds of body fluids. Like all health care workers, I put on gloves and a game face and accept such things as part of patient care.

The 2014 Ebola outbreak changes all that. It is much more dangerous for clinicians to resuscitate patients with Ebola. As a result, should we skip CPR altogether? Bioethicist Joseph Fins of the Weill Medical College of Cornell University recently suggested we should.

I disagree. See my rebuttal at Health Affairs. What do you think?