It doesn’t have to be this way, and in fact, it wasn’t until fairly recently

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few weeks ago, I was stopped in the hallway outside the ICU by a woman who had been a close friend of my sister growing up. I had not seen her in over 25 years.

She asked me to help her brother-in-law, 75, then a patient in the ICU. He was on a ventilator requiring high levels of oxygen, on dialysis for his acute kidney failure, and on medications to maintain his blood pressure. His wife had signed a do-not-resusciate (DNR) form, and the palliative care team had been called in for consultation. They advised the family to strongly consider hospice care, as there was “at best a one-percent chance” that he would be taken off the ventilator and regain consciousness.

In many cases I’ve witnessed, the transition from ICU to hospice marks the final stage, with patients passing shortly thereafter.

This friend asked me to do whatever I could to help her brother-in-law recover. I reviewed the medical record carefully and found no explanation for why he was doing so poorly. I made some changes in his antimicrobial therapy. I explained all this to the family and told them that although he was very sick, perhaps he could pull through.

Sure enough, within the next two days, his condition had turned around completely. He got off the ventilator and only required a small amount of supplemental oxygen. He started to regain his kidney function. A couple of days later, he began to eat and drink. One week from the time that I first saw him, he was discharged from the ICU and transferred to a regular bed in the hospital, breathing completely on his own.

This episode had a positive outcome. But tragically, this kind of ending is part of a steadily shrinking minority of such experiences.

This is due to a combination of factors, chiefly the rise of two new medical disciplines that are displacing the traditional patient-physician relationship, and larger societal changes. But it doesn’t have to be this way, and in fact, it wasn’t until fairly recently.

In my nearly 35-year career as a full-time attending infectious disease physician, nearly all of my work has involved inpatient hospital consultation. I see approximately 25 patients per day, on average. These patients have had a broad spectrum of severity of illness, including many hundreds, if not thousands, nearing the end of their lives. I have worked in over a dozen hospitals, in the New York area and currently in South Florida. Thus my experience is not limited to a particular hospital, nor to a particular geographic area or cultural sphere.

During this time I have watched a drastic societal shift take hold within the medical community, especially in terms of how end-of-life cases are being treated.

Working closely with Chayim Aruchim, an organization dedicated to guiding members of the Jewish community through difficult medical or end-of-life decisions, I have had the privilege of helping a number of our brethren withstand this mounting challenge. But it behooves us all as a community to be aware that this problem is gaining momentum.

In the case I mentioned at the opening of this article, was it a miracle that the patient began breathing on his own? The family thought so, as they had been told that he only had a one-percent chance of survival. But for the medical staff to have made such a dire assessment, they would have had to have cared for 100 other patients in similar situations, tried as hard as they could to help them recover, and fallen short in 99 of those cases. Suffice it to say, I don’t think any of the physicians who advised this family had anything near that kind of experience.

This is largely due to two new fields of medicine that have gradually been superseding the traditional relationship between patients and their personal physicians: palliative care specialists, and “hospitalists.”

Palliative care became a Board-recognized specialty in 2006 and has since become one of the most rapidly growing fields in the hospital setting. Its providers are trained in pain management, but more relevant to our discussion, they have assumed an important role in advising patients and their families in end-of-life matters.

When engaging in such discussions, it is crucial that patients and families have a clear understanding of the issues and the relevant medical information. The decisions often come down to whether to prioritize pain relief or prolonging life to the extent possible.

In the many, many instances when I have heard palliative care doctors presenting these options to families, only a very few did so in an objective manner. It is a fact that family decisions are influenced by how the choices are framed. And if the “experts” follow a certain bent, the families’ subsequent decisions will reflect that.

Take the following hypothetical (but all too realistic) example of a palliative care specialist speaking to the family of a 90-year-old woman hospitalized only recently due to an acute illness: “Your mother is 90 years old. She is suffering so much. We know you would not want your mother to have to endure any pain and suffering. I am sure you know she would not want it either. The kindest thing you can do for her is to make her comfortable. The right choice would be to transfer her to hospice, where specialists will manage her care.”

How would we expect an unassuming family member to respond to this? In this example, the choice has essentially been presented as: “If you care about your mother, do this. And if you don’t care about your mother, do that.” And sadly, when patients and family members oppose the direction that the specialists want to take, they are often met with multiple counterarguments and overt expressions of annoyance.

Another major change in medical care over the past 20 years has been the advent of hospitalists —physicians who take care of hospitalized patients only. This development represents a major shift in the traditional relationship between doctors and patients.

Until recently, each patient had his own physician who would follow his progress through his hospitalization. These physicians often had personal relationships with their patients, in many cases spanning decades. A physician would recall how her 85-year-old patient, now hospitalized, had been actively living life just a week or two before. This naturally resulted in the physician having a greater investment and interest in the patient’s care and recovery. The importance of this relationship and understanding of the patient cannot be overstated.

In my observation, the hospitalist who sees the patient only in a compromised state simply does not have the same motivation to help the patient recover. The hospitalist has no idea of how the patient looked just days before. No medical breakthrough or technological innovation can replace the sense of urgency and motivation felt by a doctor who had a decades-long relationship with a patient.

When the patient’s own personal physician presents the difficult options to the family, it sounds something like this: “Look, I know your mother is very sick. But I’ve known her for 25 years — I know how resilient she is. I also know how much her children and grandchildren mean to her, and how much joy she gets from seeing them. She may not make it, but I think it’s worth a shot and we should try our best. If you think she wouldn’t want to go any further than what we are doing now, let me know.”

The advantage resulting from a physician’s personal relationship with a patient isn’t just emotional connection; it lends itself to a critical element of basic medical experience.

Private physicians follow the ups and downs of their patients’ journeys. They recall moments when things looked bleak and how time, patience, and genuine care gradually improved the situation. They see not just the light at the end of the tunnel, but the actual exodus from that tunnel. Palliative care specialists, on the other hand, are trained to ease the process of dying; they lack the clinical experience to truly believe in recovery.

I remember the days when we cared for a sick patient in the ICU for weeks and the patient was eventually healed. The patient would often return a couple months later, fully dressed, looking well, delivering a box of chocolates to thank the staff for their care and attention.

I hardly see this anymore, and I often wonder if any of the hospitalists or palliative care specialists have ever experienced such moving moments. I believe that witnessing the joy of recovery would change their tone when advising families about how to proceed in their care for a loved one.

The shift in medical philosophy reflects a broader societal change. In today’s culture, quality of life — or, more specifically, enjoyment of life — is prioritized over life itself. Palliative care specialists and hospitalists tend to be younger — as they are relatively new specialties — and more aligned with contemporary values. In today’s day and age, a young, fully active individual often views old age or infirmity as an undesirable state, and this perspective will influence how they present medical choices to families.

When AI is asked to define hospice care, it gives this: “A specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally-ill patients and their families. It focuses on managing symptoms, improving quality of life, and respecting the patient’s wishes during their final days.” Note the focus on quality of life, and no mention of the value of life itself.

Yet another dynamic in the hospital that relates to end-of-life care is a patient’s “do not resuscitate” (DNR) status. When medical staff are explaining DNR to a patient or family, they usually stipulate that it is limited to a scenario of cardiac arrest: Should such a condition arise, DNR dictates that cardiopulmonary resuscitation (CPR) not be performed. Other than in that extreme situation, the patient is told that he or she will receive the same care, regardless of the DNR status.

However, while this may be true on paper, I have observed care and attention to DNR patients being withdrawn in subtle ways. For example, physicians in the hospital are generally under tremendous time pressure, and therefore must carefully decide where they will expend their efforts. A DNR order signals to a provider that this patient or family has “given up” to a certain extent.

While a particular medical provider may deny this, I have noticed it in many circumstances and in many different settings. There is no doubt that there is a letup in the intensity of care for a DNR patient. And sadly, in such settings, it is often the case that subtle variations in care spell the difference between recovery and death. As a result, I tend to educate families on the broader effects of a DNR order.

These observations and perspectives are, sadly, not based on isolated encounters. They come from spending years in the medical environment and watching its cultural evolution in real time.

I would like to conclude with how I began — a positive experience highlighting how different things could be, if proper morals governed all our actions.

Many years ago, a friend’s father, a Holocaust survivor, seemed to be coming to his end at the age of 92. The family was being pressured to place him in hospice care. After reviewing his charts, encouraged the family to wait and give him a chance. Sometime later, the patient, who was comatose, opened his eyes. Slowly but surely, he recovered, and weeks later he was back home, making Kiddush on Shabbos for his family. What this meant for him and his children!

This story is not an aberration. It is representative of what is happening in hospitals today. Advances in medicine do not compensate for changes in societal values. It takes hard work on the part of the medical team to figure out how to help extend life.

I hope that awareness of these changes will help future patients and their families make informed decisions that can literally translate into difference between life and death. It is the determination on the part of the patients and their families that most greatly impacts the care provided by their medical staff.

Dr. Daniel Berman is a Board-certified infectious disease specialist with over 35 years of clinical experience.

(Originally featured in Mishpacha, Issue 1068)