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Post-Abstract: What people think they would do to survive changes with experience
Journal Photo by Lauren Carroll
Elizabeth Callari has a question after a presentation at Hospice by Drs. Richard Stephenson Duncan Hite.
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Published: February 26, 2009
Ask someone whether he would be willing to spend 30 days in the intensive-care unit with a machine breathing for him, and he may say, "Heavens, no!"
Ask someone after he has gone through such an experience, and he may give a different answer.
"In survey after survey, ICU survivors would do it again," said Dr. Richard Stephenson, the senior vice president of medical services at Hospice & Palliative CareCenter of Winston-Salem.
The topic on the table yesterday at a forum sponsored by the Community Partnership for End of Life, which is a program of hospice, was "When Is Enough … Enough?"
The short answer is "It depends."
"It has to do with what you want as an individual," said Dr. Duncan Hite, the director of medical intensive-care and critical-care research at Wake Forest University Baptist Medical Center. "It's a very personal feeling that medicine can't define."
Stephenson and Hite touched on such topics as the importance of becoming fully informed about the long-term consequences of certain decisions. At first, people may be all for a certain path. But, when they find out that means, say, dialysis for the rest of a person's life, they may change their minds.
To provide a framework for the discussion, Stephenson and Hite examined the case of an 86-year-old man with severe emphysema who has been transferred to intensive-care at Wake Forest Baptist after going into an emergency room near his home in the western part of the state.
Because of his health, his hearing problems and his disorientation, the man was, for the most part, not in a position to clearly express his wishes. In the past, he had told his family that he never wanted to end up in a nursing home but, otherwise, his wife and two daughters were left to figure out with doctors the best path to take.
Early on, the family had made the decision to have a breathing tube inserted. During the days that followed the man's arrival at the hospital, a raft of complications arose, and Hite had a number of discussions with the family. At one point, family members decided to sign a do-not-resuscitate order. On Day 25, Hite sat down and had a long conversation in which he told them that if the man survived, the chances of his ending up in a nursing home were high.
If they wanted to keep treating him, the next step would be a tracheotomy -- making a hole so that a breathing device could be inserted through it rather than though the mouth. Then, to Hite's surprise, the man began to get better.
"Medicine is a humbling profession," he said. "Our crystal ball when it comes to these sorts of things is pretty darn foggy."
The family revoked the do-not-resuscitate order, and, when the man was in a position to speak for himself, he said that he would be willing to go into a nursing home. The last time Hite heard, the man was in long-term care.
At the beginning of the forum, Dee Leahman, the partnership's director, talked about how important it is for people to talk with their loved ones about what treatments they may or may not want. Hospice urges people to have such conversations before they find themselves in such stressful situations as an intensive-care unit.
Hite agreed.
"It's not an environment in which optimal decision-making can be done," he said.
He also made the point that the conversation shouldn't be thought of as a one-time thing. It's one thing when you're talking about something in the abstract. It's another when it's a matter of life and death.
"It's easy to say, ‘I never want that' until you are facing the end of your life," he said. "Attitude can change pretty dramatically."
"Re-ask those questions," Stephenson said.
■ Kim Underwood can be reached at 727-7389 or at kunderwood@wsjournal.com.
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