What I'm reading: Daniela Lamas's "When the Treatment of Last Resort Sends a Life Into Limbo."
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What I’m reading: Before my shift today, I read a superb essay in the New York Times, written by my Brigham and Women’s Hospital colleague, Dr. Daniela Lamas. Lamas is an ICU doctor that I sometimes work with, and so we are friendly, although I think we’ve only met on the phone and on Zoom! Her essay is entitled, "When the Treatment of Last Resort Sends a Life Into Limbo,” and I encourage you to read it. After my shift, I texted her to congratulate her, chat about the essay, and ask her what more I should tell you all about it (more on that below).
Lamas’s essay is about a treatment called ECMO (for extracorporeal membrane oxygenation). More or less, ECMO is lung bypass. The machine pulls blood out of the body, does the work of the lungs, and then puts the blood back in.
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The problem is, as Lamas writes, ECMO is designed to be a bridge to definitive treatment—say, a lung transplant, or fixing whatever is causing the lungs to fail, rather than a destination unto itself.
But increasingly, ECMO is being used on patients who doctors don’t actually think have a chance at a meaningful recovery. I’ve seen ECMO successfully used, and in the right patient, it buys much needed time. In fact, I’ve had patients who were on the brink of death go on ECMO, and eventually walk out of the hospital (albeit weeks or months later) just fine. But I’ve also seen what Lamas describes: ECMO is increasingly being used in ways that prolong suffering, often taking the place of frank conversations with patients and their families about realistic prognoses. We doctors hate talking about the end of life. So, we avoid it, whenever we can, it seems. Offering ECMO is yet another thing we can offer, instead of difficult, but much-needed conversations.
Sadly, history is repeating itself. In the early days of CPR, researchers knew that if those techniques were applied to the wrong patients, the result would be prolonged suffering only. In fact, while describing their early successes in a landmark paper, the CPR pioneers themselves specifically cautioned their colleagues—and us—against using their refined techniques indiscriminately. Read their prophetic words:
These researchers knew exactly what they’d accomplished, and they also foresaw how their methods could be misused, simply by being overused. I know if they saw how we use CPR today, they’d be devastated. We so often do what they admonished us not to. Yes, we use CPR for the patients they envisioned it could help, and often with outstanding results. (Learn CPR! The important parts are truly easy.) But, regrettably, we also use CPR on precisely the patients they told us not to; patients with irreversible medical problems in whom restarting the heart does nothing other than to prolong suffering, adding no chance of regained consciousness or any type of meaningful recovery.
It seems we are now doing the same thing with ECMO. I texted Daniela this evening both to congratulate her on the essay, and to share these thoughts with her and get her reaction. (As doctors who write, we sometimes talk and compare notes.) I asked her if there was anything she’d add for Inside Medicine readers. She said that “any awake ECMO should be an automatic palliative care consult, that’s for sure.”
It’s both difficult for me to believe—and also absolutely credible, given what I know about modern medicine—that not every patient being placed on ECMO has had a doctor talk to them about end-of-life care. It’s disappointing and it rings true.
In modern medicine, we too often avoid difficult conversations with our patients. The better our technology gets, the longer we can prolong life. While it might seem counterintuitive, some of these advances actually makes such conversations all the more important.
Did you find this helpful? Inside Medicine is written five days per week by Dr. Jeremy Faust, MD, MS, a practicing emergency physician, a public health researcher, and a writer. He blends his frontline clinical experience with original and incisive analyses of emerging data—and to help people make sense of complicated and important issues.
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“Modern medicine is good at staving off death with aggressive interventions—and bad at knowing when to focus, instead, on improving the days that terminal patients have left.”
Atul Gawande, From “Letting Go” a 2010 article in The New Yorker.