A Great Privilege to Die Beneath an Open Sky 

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Chandrakanth Are, MBBS, FRCS, FACS

It was 1:00 AM, and my beeping pager awakened me. When you’re a surgical oncologist, you know that a page from your chief resident at this hour of the morning usually means someone may need to go to the operating room. And, yes, it was the chief resident about a patient in crisis. Except in this case, it was not an easy decision to make.

Case Notes

The patient was a 50-year-old male with known metastatic pancreatic cancer, liver metastasis, and peritoneal carcinomatosis. He was cachectic, weak, and had biliary stents for jaundice. He had been on palliative chemotherapy for several months. In the past few days, he started complaining of increasing abdominal pain and worsening of his weakness.

A CT scan demonstrated a large pneumoperitoneum for which we as surgeons were consulted. The patient was a “full code,” and no prior discussions had been held with the patient or the family to determine the appropriate course of action in emergency situations such as these. The patient had a young child and hailed from a different country and culture, which only added to the ethical and moral complexity of the case. The patient and his family wanted everything possible to be done despite our explaining the likely futility of operative intervention.

We took the patient to the operating room and found extensive carcinomatosis and a large volume of purulent fluid. The patient’s abdomen was washed out, and drains were left in place.

Ingrained Need to Intervene

As physicians, we go through medical school/residency and sometimes fellowship to learn about the art and science of practicing medicine. We start out in awe of the marvel of the human body during our baptism into medical school via the cavernous halls of anatomy lab. Then we learn of the physiologic pathways and reflexes that govern the intricate functioning of the body.

We become acquainted with the large number and myriad types of diseases that can inflict varying degrees of damage to the body. This is capped off by grasping the different methods of diagnosing and treating these various diseases. The intelligent exercise of weaving through the process of differential diagnosis is matched by mastering the technical skills to nimbly excise disease through surgical procedures.

Through all of this instruction, we teach that to treat patients, we must do something. We must intervene and continue to intervene throughout their treatment. This intervention can be simply an investigation, ranging from a simple blood test to a sophisticated radiologic study. Or it can include prescribing drugs, which may cost next to nothing or may be more expensive than the monthly salaries of many health-care providers. Or it could involve surgical procedures that extend along a spectrum from a simple lymph node biopsy to complex and morbid multivisceral resections.

The common theme through all of these is that there be an “active intervention.” Because not intervening would go completely against what is ingrained in us and what we have become accustomed to. (The robust medical malpractice industry does not help either, making us do things that we otherwise might not.)

‘Doing Nothing’

Where does the option of no intervention fit into the picture? How often do we tell patients that there will be no intervention-based treatment? How often do we tell them that we will have to wait for nature to take its course or give nature time to heal them? And how often do we tell them that no matter what we do, the outcome is going to be poor? The background of our training combined with the fear of malpractice and current societal expectations hinders us from doing this more often than we actually should.

While physicians are held at fault for malpractice, they are also expected to be infallible, have the ability to cure anything, and emerge as victors in the arena of sickness. Society expects perfect outcomes despite the vagaries of human diseases and the abuses that patients put their own bodies through. Some might even consider death an optional outcome because of the incessantly dished out media hype about the superhuman capabilities of the medical profession.

This predicament is furthered by the notion among medical professionals that “doing nothing” is a sign of failure. Giving up on the patient can cause pangs of guilt in physicians who are groomed never to fail.

We stand to do a great disservice to our profession and our patients by not teaching and emphasizing the value of “doing nothing.” This also embodies the moral principle that governs our profession: “primum non nocere” or “first, do no harm.” The current thinking and type of practice needs to change. This should start with teaching that “doing nothing” is not a sign of failure.

Teaching that you can view “doing nothing” as a type of intervention can also be helpful. Highlighting the futility of active interventions when the outcomes are universally poor can help in choosing this pathway of treatment. Physicians should be taught that the success of a treatment should not depend on whether it includes an intervention. Instead it should be based on what is right for the patient, even if it means “doing nothing.”

Physicians should not be made to feel that “doing nothing” will be perceived as doing less work. In fact, not intervening usually takes up more time than more easily ordering an intervention. Not operating takes up more time—in light of repeated family meetings and multiple discussions to explain why we are not operating—than operating, which is more straightforward. After balancing the pros and cons of everything, we should do what is in the best interests of the patient, even if it means “doing nothing.”

Moral Imperative

The more important reason for “doing nothing” is based on a moral imperative. If we feel that an intervention will not help the patient but may, in fact, make them worse or prolong suffering, we are the bearers of that responsibility to not intervene as such. Although it may be difficult, we should shed the feeling of guilt, spend more time in explaining to and comforting the family, dispel the inner fear of malpractice, and recommend that “doing nothing” is the best course of treatment. This will inflict the least amount of suffering on the patient and family members.

If an intervention is warranted, we should aggressively pursue it. But if it is futile and likely to prolong suffering, we should be even more aggressive in “doing nothing.” We should not only be the bearers of medical information but also be the informed shoulder that can share the burden of jointly making the difficult decision of “doing nothing.” Only then are we satisfying all the medical, ethical, moral, and humanistic requirements of our profession. That is what patients should expect from us, and we should give them no less.

Closing Thoughts

This patient did well during his intraoperative and immediate postoperative course. But thereafter, his status fluctuated, and he finally succumbed to his disease during the same hospital admission, just a few weeks after the operation.

The patient got to spend an extra few weeks with his wife and child, which we cannot place a value on. On the other hand, we raised the false hope of survival, which ultimately came to nought. The patient could have gone home and spent the last few days of his life with his family in the comfort of his home, with dignity. Instead, he spent the last days of his life in a hospital room surrounded by well-intentioned, hard-working people who were nonetheless strangers to him until this admission.

As one of my mentors always used to say, it is a great privilege to “die beneath an open sky”—in other words, it is a luxury these days to be able to die in the comfort of your own home. Instead, most spend the last days of their lives in the technologically advanced, sophisticated, and rigid but artificial confines of a hospital or other health-care facility. If only more physicians practiced the option of “doing nothing,” there could be as much dignity in death as there is joy accompanying the birth of an individual. ■

Dr. Are is Associate Professor of Surgical Oncology, Vice Chair of Education, and Program Director of the General Surgery Residency Program at University of Nebraska Medical Center, Omaha.

Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO. Some details have been changed to protect patient privacy.