Philipp Kolb is a final year medical student at McMaster University
One of the joys in my life right now involves a beautiful ride along the Hamilton Escarpment home from the hospital on a vintage road bike I fixed up over the course of the COVID-19 pandemic. I stripped and replaced every piece of cable, buffed the chrome features, and completely refinished the frame in complete with original stickers and markings. As I make my way down the escarpment during these rides, I always find a moment for peaceful reflection before the reality of exams, laundry, and making sure I have a lunch for the next day hits me the second I get home. During these moments I often find myself letting gravity roll me home as I stop to reflect…
Riding to the Juravinski Hospital one day as the winter snow finally dissipated into the warm green glow of spring, I felt hopeful looking over the city. The sun peeked through the clouds and the buds began to blossom – a rebirth.
My shift that day involved a patient coming into the department with acute-onset altered mental status and general weakness. The patient was at an advanced stage of cancer, which had spread throughout his body and included metastatic disease in the brain. Diagnosed both clinically and through imaging, he had presented today with pneumonia and I was tasked with communicating this information to his son who sat quietly in the isolation room. Wearing my yellow gown, I approached a man, not much older than myself, to communicate the news and discuss the options still available for consideration. He was aware that his father was sick and that we were approaching the end of his life. Still, as happens all too often, we found ourselves in an emotionally challenging goals of care discussion in a busy emergency department – does this patient want to receive an IV antibiotic to treat his infection, or not? What were his values and wishes? Would he want to die peacefully, or fighting until the very end? The easy answer is to treat an infection; we are, after all, a culture that feels the need to at least do “something”. While it was made clear by the patient that his wishes were to withhold any CPR or intubation, a discussion was never had about what he would want in his final weeks and days, rather than just his final moments. I do not claim to know the right answer. To be honest, I am not sure there is one.
As I rode my bike, the wind blew a steady warm breeze through my helmet, I was reminded that in medicine, unlike in the spring-time year after year, there may not be an opportunity for rebirth for all of our patients. The buds may not blossom. The songbird may not sing again. I wondered, would the IV antibiotics just prolong and complicate the dying process? Would there be side effects that create more suffering for this patient? Or would treatment provide the patient I saw with an opportunity to say goodbye? Would it allow him to recover from an acute treatable illness and feel the warm sun on his skin before the cancer in continued to spread? I will always wonder…
This type of uncertainty is constant in medicine and, as a future physician, experiences like this make it clear to me that we need to have more consequential conversations about death and dying. It’s clear that we need to reshape the conversation from a blunt and medical-legal approach of noting in a chart an answer to the question:
“Do you want heroic measures at the end of your life – these would include CPR which involves us mechanically beating your heart and breaking your ribs in the process? Do you want a breathing tube inserted into your lungs?”
We owe it to our patients, to our loved ones, and to ourselves to have longer, more meaningful conversations about death. These conversations should focus not just on what’s important to a patient in the context of a sudden catastrophic event such as an MI or respiratory failure, but also in the setting of the gradual decline that coexists with much of terminal illness, frailty, and organ failure. Like so many of us in healthcare, I believe strongly in the healing power of human kindness combined with modern medicine. However, there is a painful reality that, unlike a vintage bicycle, there are some things even the most powerful science cannot fix. After a beautiful life, I believe there is dignity in a peaceful death which follows a certain natural progression. As I meander down the curving escarpment, I reflect not just on my experience here but also on the words of Sir William Osler, “Pneumonia may well be called the friend of the aged…”
You are wise beyond your years. Beautifully written.
John Crosby, family physician for 49 years.