Week 6 - Amanda

After a week devoted to my research project, I spent this week on clinical rounds and seeing surgeries. I chose to go to the Medical ICU (MICU). None of the other immersion students had attended their rounds before, so I decided to be the first and was quite surprised by it. I rounded with Dr. Berlin, the attending physician. I had seen him weeks before in the ER, as he became the physician responsible for the older lady with pneumonia who came in unresponsive. There were several young residents on the rounding team, and Dr. Berlin was quite actively teaching them how to think like ICU doctors. Whenever the residents gave Dr. Berlin a "textbook" answer, he challenged them to look beyond the "right" answer, and to base most of their decisions on clinical symptoms. For example, if the patient appears to be doing better on the current treatment plan, perhaps it's a good idea to continue that treatment, rather than chasing down every possible symptom and potential pathology the patient might have. I found this viewpoint rather unique to the ICU, since their main goal is to get the patient out of their department. They focus on the immediate symptoms, and not necessarily the longterm health of the patient.

While many of the MICU cases were interesting, an interesting ethical questions came up during the rounds. A patient came in with serious metastatic cancer. He was in his late eighties, and had metastatic masses spread throughout his brain and multiple organs. He went into heart failure in the hospital department that he was receiving treatment in, and a doctor managed to revive him after extensive measures. During rounds, Dr. Berlin was very frank with his residents and voiced his opinion, which I'll try to summarize:

 According to him (and it was quite obvious from the patient's report), the patient was dying. Everyone reaches that point eventually where systems begin to fail, whether from cancer, cardiovascular disease, or just old age. Dr. Berlin was upset (for the sake of the family and the patient) that the attending doctor had revived the patient, but even more-so that procedures were still being performed on him. At what point do you decide that enough intervention has been performed? Imagine that you're a part of the patient's family, and a doctor comes to you and says, "He's in serious shape, but we'd like to try a few things. We can do an MRI to see how the cancer is progressing. We can also try to give him _____, a drug that will maybe improve _____. We can also try ____ procedure to see if we can fix _____." As a family member, what are you going to say? "No, let's not do a procedure that might save my family member's life?" By the doctor offering all these procedures, it gives the family hope that something can still be done, and they feel obligated to accept. You can perform procedure after procedure, but at a certain point, there's not much you can do. It's really the duty of the physician to realize when it's time to stop, and to tell the family that it's over. Spend the rest of the time making the patient comfortable, not doing useless procedures to treat symptoms.

For me, this was a point of realization. This was a responsibility that a doctor carries that I had never considered. How many doctors are recommending procedure after procedure, getting carried away by the details of the patient's care? I believe a responsible doctor would fully inform the patient's family of the big picture - what organ systems are failing, etc, etc - and put the procedures they're suggesting into perspective (this procedure may not help much. It may be better to just make the patient comfortable at this point). However, the ultimate choice lies with the patient and their family.