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Abstract

The House of God found it difficult to let some young terminal guy die without pain, in peace. Even though Putzel and the Runt had agreed to let the Man With Agonal Respirations die that night, his kidney consult, a House red-hot slurper named Mickey who'd been a football star in college, came along, went to see the Agonal Man, roared back to us and paged the Runt STAT. Mickey was foaming at the mouth, mad as hell that his “case” was dying. I mentioned the end-stage bone cancer, and Mickey said, “Yeah, but we've got an eight grand dialysis shunt in his arm and every three days the dialysis team gets all his blood numbers smack back into line perfect.” Knowing there was going to be a mess, I left…. I thought of the bones in multiple myeloma: eaten away by the cancer until they're as brittle as Rice Krispies. In a few minutes the Man With Agonal Respirations would have a cardiac arrest. If Mickey tried to pump his chest, his bones would crunch into little bitty bits. Not even Mickey, seduced by the Leggo's philosophy of doing everything always for every patient forever, would dare call a cardiac arrest.

Mickey called a cardiac arrest. From all over the House, terns and residents stormed into the room to save the Man With Agonal Respirations from a painless peaceful death. I entered the room and saw an even bigger mess than I'd imagined: Mickey was pumping up and down on the chest and you could hear the bones snap, crackle and pop under his meaty hands: a Hindu anesthesiologist pumped oxygen at the head of the bed, looking over the mess with a compassionate disdain, perhaps thinking back to the dead beggars littering dawn in Bombay: Molly [a nurse] was in tears, trying to follow orders, with the Runt shouting, “Stop! Don't resuscitate him!” and Mickey cracking and crunching and shouting, “Go all out! Every three days his blood numbers are perfect!”¹

She had a blood pressure of 40 for three or four days and we gave her wide open drugs to keep her pressure up. This lady was bleeding out of her eyes, her ears, her mouth, and she was blown up like a toad. We put washcloths over her eyes and within two minutes they were saturated with blood. When she finally started coding, they actually did CPR!… The resident on the unit at the time had very strong belief that this was cruel and he told the attending doctor “If you code her, I will walk out of this unit.” And the attending said, “No you won't,” and the resident said “Yes, I will,” and that is exactly what he did…. I first thought this attending was acting because of legal aspects, but now I think it was a power trip–it was like he was saying “We're not going to do what you want, I'm the one who is in control here.”²

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References

Shem

, The House of God (New York: Dell, 1978), pp. 285–86 (emphasis added).

A critical care nurse, as quoted in McCrary

S.V.

, “Dwelling in the Shadow: Physicians” Decision Making for Terminally Ill Patients” (Galveston, Texas: University of Texas Medical Branch, Ph.D. dissertation, 1992) (emphasis added).

Solomon

M.Z.

, “How Physicians Talk About Medical Futility: Making Words Mean Too Many Things,” Journal of Law, Medicine & Ethics, 21 (1993): 231–37.

President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Deciding to Forego Life-Sustaining Treatment (Washington, D.C.: U.S. Government Printing Office, 1983).

Scitovsky

A.A.

, “The High Cost of Dying’: What the Data Show,” Milbank Quarterly, 62 (1986): 591–608.

See Solomon, supra note 3.

Id. at 231.

Id. at 233.

McCrary

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Swanson

J.W.

Perkins

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and Winslade

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, “Treatment Decisions for Terminally Ill Patients: Physicians” Legal Defensiveness and Knowledge of Medical Law,” Law, Medicine & Health Care, 20 (1992): 364–76.

10.

See McCrary, supra note 2; McCrary, Swanson, Perkins, and Winslade, supra note 9; and McCrary

S.V.

Swanson

J.W.

Youngner

S.J.

Perkins

H.S.

and Winslade

W.J.

, “Physicians” Quantitative Assessments of Medical Futility,” Journal of Clinical Ethics, 5 (1994): 100–04.

11.

See McCrary Swanson Perkins and Winslade , supra note 9.

12.

See McCrary Swanson Youngner Perkins and Winslade , supra note 10.

13.

Fleiss

J.L.

Williams

J.B.

and Dubro

A.F.

, “The Logistic Regression Analysis of Psychiatric Data,” Journal of Psychiatric Research, 20 (1986): 145–209; and Hosmer

D.W.

and Lemeshow

, Applied Logistic Regression (New York: John Wiley, 1989).

14.

More specifically, logistic regression makes inferences based on the sampling distribution of the natural logarithm of the odds ratio, which approximates a normal distribution even with fairly small sample sizes. The logistic coefficient yields the estimated odds ratio by which an “event” is associated with some predictor variable that controls for the other predictors in the model. The square of this parameter divided by its standard error yields the Wald chi-square statistic, which can be used to test the statistical significance (or probability of true effect) of each independent variable with respect to the chi-square sampling distribution. Finally, the logistic regression equation yields a predicted probability of the event for every combination of independent variables included in a model–for example, the probability that physicians with a particular profile of attitudes and characteristics will deny futility. Upper and lower confidence bounds for these predicted probabilities are calculated as well. The overall “fit” between predicted probabilities and actual responses in the entire sample allows an assessment of whether the model has been adequately specified, that is, whether relevant predictors have been included, and thus whether the model offers explanatory power for making inferences about true relationships between variables in the population. Predicted probabilities generated by logistic regression are especially useful for examining the estimated magnitude of the effect of combinations of independent variables that may occur in small numbers in a sample, for which a straight percentage rate would be unstable.

15.

See McCrary Swanson Youngner Perkins and Winslade , supra note 10.

Doing All They Can: Physicians Who Deny Medical Futility

Abstract

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References