Bo Zheng is an emergency medicine resident physician at the Ottawa Hospital and the University of Ottawa.
“He’s a fighter," the daughter of a critically ill senior patient proudly told me, something I’ve heard many times.
“He’s going to keeping battling. He would never give up.”
I wasn’t sure if she understood that her father had almost no chance of recovery. And even if he did, he would not return to a quality of life anywhere near what would have been acceptable for him.
References to war and combat are pervasive in health care. From “fighting” a cold to “battling” cancer, these metaphors are often used as a way of providing motivation and hope. Unfortunately, they also lead to unrealistic expectations in the context of serious illness and end of life. They imply that patients and health care providers should do everything they can to fight the disease. They create a dichotomous win-or-lose paradigm, which can be both harmful and demoralizing for patients.
As a physician on the “front lines,” I have seen countless patients with life-threatening illnesses who, with their families, are often insistent on fighting until the end. I have seen patients with advanced cancer on their third or fourth option for chemotherapy not wanting to “give up” on the battle. I often see these patients suffering from complications and side effects of their chemotherapy, some of them dying a prolonged and painful death.
In the era of COVID-19, we are faced with yet another “war.” I appreciate that framing the pandemic this way highlights the gravity of the situation. The government needs to mobilize resources and implement unprecedented “wartime” measures. The public needs to know they can do their part by staying home and physically distancing. Military analogies provide solidarity and a sense of community during times of crisis.
But managing a medical illness is not the same as fighting a war. When people die from an illness such as cancer or COVID-19, it does not mean that they have “lost the battle,” that they lacked determination or moral character, or that the health care team did not “fight hard enough.”
Physicians should “cure sometimes, treat often and comfort always.” This aphorism could not be more true today. We currently do not have a cure for COVID-19, among many other diseases. While over 90 per cent of patients with COVID-19 will recover, a significant proportion will not.
Modern life-sustaining therapies such as ventilators and heart and lung-bypass machines can keep almost anyone “alive” for an indefinite amount of time. This is what we call supportive management. We are prolonging life without altering the natural course of the illness. The longer patients are in this state, the smaller their chances are of recovering and the higher their chances are of developing blood clots, hospital-acquired infections and other complications. If patients do not recover, difficult decisions must be made by their families and health care providers about how long to keep going.
Most people would not want to be in a comatose state, with their breathing and circulation controlled by machines, if they have no chance of meaningful recovery. But if the mentality is that we need to do everything we can to fight COVID-19, I’m concerned that overly aggressive therapies may be instituted inappropriately and at the expense of quality of life, personal values and health care resources.
Sometimes the most compassionate treatment for a severe illness is to alleviate symptoms and ensure comfort. Exempting patients from life-sustaining therapies, however, does not mean that they are left to die. A multitude of treatments are available for pain, shortness of breath and other symptoms associated with the end of life. The goals of treatment are different for every patient. For some, a comfortable and dignified death may be the most optimal outcome. It should not connote a battle that was lost.
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