Time to Make a Choice

Often, I write amusing EndoNurse essays. Warning: This ain’t one of them. I’ll assign blame for this rant to editor Kathy Dix — she wound me up and let me go, which I believe to be part of an editor’s job description.

People in healthcare sometimes have to do things against their will. And I don’t mean crack-o-dawn elective cases, weekend quasi-endoemergencies, or three-hour ERCPs. I mean the deep ethical dilemmas in which your refusal to provide care may put your job in jeopardy.

Recent news discusses pharmacists who reject on ethical grounds the filling of prescriptions for the ‘morning after’ pill. Can they refuse to fill a valid prescription from a licensed healthcare professional? Apparently they can and do.

During internship, I wondered about the OB residents who had to learn to perform abortions, although against their beliefs. I myself am ‘pro-choice’ (too many of my teachers had practiced in the days of botched back-room abortions, perforated uteruses and septic women). My own beliefs were sorely tested when taking medical histories of young women and discovering they’d had three or more abortions, using abortion as their sole method of birth control. It made me consider tying them down for a little rant about safe sex and a tubal ligation.

Gastro folks don’t have such dilemmas, or do we?

Terri Schiavo’s story finally ended. Which camp were you in? Was she alive and responsive to her parents, and deserved to be fed? Where any spark of cell life is sacred? Or were you in my camping grounds, where I grieved for her parents who deluded themselves, found one old still photo in which Schiavo seemed to make eye contact with her mom, and broadcast it to the world?

Editor Dix sent me the link to a disturbing Washington Post article that discussed more than a dozen states considering new laws to protect healthcare workers who do not want to provide care that conflicts with their personal beliefs. This legislation reflects the intensifying tension between asserting individual religious values and defending patients’ rights.

Advocates for end-of-life care are alarmed that the laws would allow healthcare workers and institutions to disregard terminally ill patients’ decisions to refuse resuscitation, feeding tubes, and other invasive measures.

I am pragmatic in my beliefs about percutaneous endoscopic gastrostomy (PEG) tubes and nutritional support. I personally support those who want to mimic an aged Native American, slipping off to the wilderness to die when useful life is over. PEG tubes are great when used as a bridge to recovery, and cruel when used to prolong inevitable death. At the request of patients, I have removed PEG tubes that I thought should stay put, as in the case of an elderly lady recovering from a devastating stroke, whose cine-esophagram showed major aspiration risk from vallecular pooling of liquids. But she was competent (as she had not been when we placed the tube), so out it came.

I have also put in, repaired, and replaced PEG tubes in those whom I consider the living dead, husks without divine spark, and yet who continue to breathe. You in endoscopy know these poor shriveled shells of people — you’ve had to pry their contracted arms and knees away from their abdomens to use those Betadine swabs. Many have been discarded to the sterile arms of hospitals, long-term care facilities, and nursing homes, with no visitors for months to years.

As a young GI trainee, I asked why their families would continue supportive care; the curt answer from the senior GI fellow was “disability checks.”

A story went around when I was in training of a heavily tattooed biker, severely injured in a motor vehicle accident and brought to our emergency department. As the trauma team worked frantically to save his life, anesthesia struggled to intubate his damaged face. The anesthesiologist broke into seemingly inappropriate laughter as he completed his intubation. His explanation when the crisis was over? “The guy had an epithet tattooed inside his lower lip (which said — in terms not publishable in this magazine — ‘go away!’) ... seemed like a clear DNR order to me!”

So do you, like so many of us in endoscopy, plan to have an explicit “Do Not PEG” tattooed at your bellybutton? Have you made your choice about how you wish to exit? Do you have a living will? A durable medical power of attorney? Most healthcare professionals know how far they want to push it — we “get” that death is eventually inevitable. But what if you are no longer captain of your own vessel? Does your family know what you want?

I have both a living will and a durable medical power of attorney, assigned to my brothers. My explicit choice is if, after six months of full supportive care, I don’t interact with my environment, enjoy being with people or my family, and don’t appear happy, and my neurologist feels that there will be no additional improvement, they are to pull the plug. Not literally, but even in a vegetative non- brain-dead state, they are to stop feeding and watering me. No antibiotics for pneumonia or the inevitable UTI.

My brother Mike says it’ll be his pleasure to ‘off me.’ He watches HBO’s ‘The Sopranos.’ I try not to make him mad.

I don’t believe that we healthcare professionals get the final choice in our patient’s healthcare decisions. You go into healthcare, you inform your patients of all options, and then respect their choices. But for your own life, and death, the choice is yours. Make your wishes known.

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