Doctor of Medicine
Ruth was a Jewish woman in her late 70s with end-stage Chronic Obstructive Pulmonary Disease (COPD) who was rushed to the hospital because she couldn’t catch her breath. At the hospital, she told a nurse that she did not want artificial feeding or to be resuscitated if something were to happen to her. However, she did not want to sign a Do Not Resuscitate (DNR) order because she said it was against her religion. Her condition declined and she was intubated and cared for in the Intensive Care Unit. Her closest family members were two sisters who lived out of town but arrived a few days after she had been in the hospital. One sister was the Durable Power of Attorney (DPOA) for Healthcare, but did not know her sister’s wishes regarding treatment.
As a part of the Palliative Care Team, I met with Ruth’s two sisters about her prognosis. I explained the option of extubation and hospice care. Although there was a possibility that Ruth would breathe on her own after she was extubated, it would not make sense to also remove the endotracheal tube, if her sisters wanted her re-intubated if she had additional difficulty breathing once she was extubated. Doing so would likely lead to a Tracheostomy and Percutaneous Endoscopic Gastrostomy (PEG) and tube.
Ruth’s other (non-DPOA) sister immediately said, “There is no way my sister would want to be extubated and I will not agree to hospice.” Since Ruth was conscious, we were able to explain the options to her. She was able to nod "yes" to removing the tube and “no” to re-intubating if she could not breathe, even though she may die.
The team left the room and Ruth’s other sister stayed behind. After awhile, the sister came out of Ruth’s room and said that Ruth's sister did not want the tube removed. I asked Ruth’s other sister (with DPOA) to make the decision. She was torn and overwhelmed and could not make the decision. To further complicate matters, the sisters were not in agreement about what to do. Several days passed and Ruth’s sister with DPOAH could still not make the decision to extubate. I met with her again and explained what was happening to Ruth’s organs. Her sister, full of uncertainty and guilt, and in discord with Ruth’s other sister, decided to have Ruth extubated. The other sister vowed to never speak to her again.
As a hospice and palliative medicine physician, I live this story every day with different patients and different families. So much of the pain, suffering and family discord can be prevented if physicians have a conversation about advanced care planning with their patients much earlier.