Many doctors believe their job is to try to preserve life at all costs, says Cleveland Clinic CEO and President Toby Cosgrove, MD. That’s what he believed early in his four-decades-long former career as a cardiothoracic surgeon.
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Yet he has learned that saving a life is not always in the patient’s best interests, he says. That’s why conversations between doctor and family about end-of-life care are critical.
Dr. Cosgrove explains his views in these highlights from a discussion with two end-of-life care experts: palliative medicine specialist Krista Dobbie, MD, and cardiologist Eiran Gorodeski, MD, MPH.
A shift in perspective
Dr. Dobbie: What prompted you to revisit your thinking around end-of-life care?
Dr. Cosgrove: One case stands out. I had operated on a patient twice. She lingered for a long time afterward. I was essentially unwilling to give up. The family saw me continue to press on but eventually said, “We think it’s enough.” They realized it was time to stop the support, and we did.
I learned from that situation that you can sometimes be too persistent. So I started talking with families. I would tell them I’d persist in fully supporting the patient as long as we thought he or she could return to being a functional member of society. If it got to the point where I didn’t think that would happen, I would come and talk to them about it.
Uniformly, they all said, “Thank you, doctor, we really appreciate that.” It relieved both them and me of tremendous anxiety.
Dr. Dobbie: Why is it so difficult for doctors to give up?
Dr. Cosgrove: Doctors are doers. Being comfortable with ambiguity is not in our training, and it’s not in our nature. We now have so many tools — ventilators, dialysis, you name it — to save lives, and no doctor wants to lose a patient. But lifesaving measures may come at a cost to the patient.
That’s why we need to ultimately go to the family and say, “It’s come to the point where I don’t think any more activity is going to benefit your loved one.”
Dr. Gorodeski: This is the essence of the empathetic, constructive conversation that needs to become routine between doctors and families.
Dr. Cosgrove: Doctors are not generally going to be the ones making the decision about end-of-life care. Instead, we serve as the advisers, the providers of information and the listeners so that we come to understand where the patient and the family are.
Dr. Dobbie: End-of-life decisions can be overwhelming to patients and families.
Dr. Cosgrove: I’d like to see healthcare providers become more comfortable in setting the stage for these discussions. We need to let families know that death doesn’t have to happen in the ICU, where it increasingly seems to take place.
Death can happen at home, in hospice, in palliative care or on the ward. Part of allowing people to die with dignity lies in not reducing them to feel that they’re consuming everybody’s emotions and resources.
A delicate balance
Dr. Dobbie: There are cases where continuing with really aggressive care enables tremendous saves. I’ve seen young people struggling in the ICU who pull through because a donor heart or lungs become available.
Our culture struggles with properly balancing these cases against cases where it makes sense to say “enough.” Because sometimes current care can actually add more suffering. Our bodies have been programmed to shut down during a process that can be very peaceful and painless. When we intervene with ventilators and tubes, we risk messing up that process.
Dr. Cosgrove: That’s one of the big dilemmas in healthcare today. We have so many capabilities now that we need to stop and ask ourselves, “Do we take this next step? The patient may live, but with what quality of life?”
Is taking a 92-year-old patient to the ICU, putting in a balloon pump and placing them on a respirator the right thing to do? Sometimes such interventions aren’t even desired. They happen because there isn’t enough discussion between providers and families about what’s really wanted.
Dying is a natural act, just as being born is a natural act. The focus should be on allowing people to die with dignity when other options acceptable to the patient and family run out.
We are getting better and better at predicting which patients are going to make it, based on a host of variables, but it’s still a tough call. There is no black-and-white answer. These are hard, hard decisions.
Death is natural, but we remain uncomfortable with it — all of us. I don’t know how you get people comfortable with it. I’m just trying to start the conversation.