At the end of July, the health authority in Starr County Texas, Jose Vazquez, MD, said that patients with COVID-19 deemed unlikely to survive would be “advised to go home to loved ones” due to limited hospital capacity. Those words were used by news outlets to imply that people who could otherwise be saved would be sent off to die.
Doctors can determine when patients are close to death. Doctors can determine when medical interventions will be futile. However, certain clichés have gotten into the public realm that hinder these determinations. Those clichés include — “No one has a crystal ball” or “miracles happen” or “you never know” or “never give up,” etc. Some even hold that for a doctor to say a person will die soon is to play God.
In my opinion, it is playing God to put a patient on a ventilator when it is clear that the ventilator will not turn things around. It is playing God to pretend that you can beat death when there is no way you can beat death.
However, having worked in critical care hospitals for over 30 years, I have seen this often happen; I have seen patients put on ventilators when it was clear that the ventilators would only prolong suffering.
Over the years, I cared for many patients who had a new cancer diagnosis. Sometimes I knew, at the time of diagnosis, that the cancer would be terminal. For example, pancreatic cancer, if it cannot be surgically removed, is terminal. However, when I made a new diagnosis of pancreatic cancer in a patient, I never gave a specific time limit on life. That is because no one can predict such a limit without following the patient and observing how that patient responds to treatment.
But once I followed those patients for a while, once I saw how the cancer was progressing and how their bodies were progressing, then I could predict, in a more reliable fashion, how soon they would die. For example, if the cancer grew in spite of chemotherapy, if the patient developed more pain and lost a lot of weight, if other organs (such as the kidneys or liver) began to fail, then I knew the end was near.
In other words, just because we don’t have a crystal ball and just because some doctors are foolish enough to make unjustified predictions about death right off the bat, that does not mean that a competent doctor who observes a patient over time cannot make such predictions. When a patient is dying from terminal cancer, when it is clear that the end is near, it is cruel to put that patient on a ventilator or do other things that cause pain and discomfort. The same is true for patients with COVID-19. There are times when these patients are too far gone to be saved.
We do not have a cure for COVID-19, and we do not have any good therapies. We have a lot of hype about this or that supposed cure, but nothing reliable. The vast majority of people with COVID-19 get better or worse depending on how their bodies respond to the virus. Some get worse and there is nothing we can do to stop that from happening.
We have never had good therapy for respiratory viral infections. The common cold is caused by a virus. We have no therapy for the common cold. Flu is caused by a virus. We have a medication for flu, but it is not very effective. We have good treatments for chronic viral infections, such as HIV and hepatitis C. But it is a biological reality that acute respiratory viruses resist our attempts at cures. The only effective technology to get rid of respiratory viral infections is vaccines. In other words, once a person’s body is failing due to a COVID-19 infection, we don’t have medications to dramatically turn things around.
When Vazquez spoke about those with COVID-19 who would be sent home to die, he was talking about those who had been treated with our limited medications, but were failing nonetheless. They are patients who doctors know will die soon. Keeping them on machines does not cure them. Nor does it allow them to get better and go home. Instead, it just prolongs the suffering. It also forces them to die alone, hooked to a machine. Dying in that manner is brutal; it is not compassionate or kind.
Death is inevitable. We all must face it. We all have a choice whether to face it with strength or weakness. Over the years, I have seen patients face it with strength. I admire them. I hope I can be as strong when my time comes.
I have also seen weakness to the point of insanity. I saw one patient who died from pancreatic cancer but was kept on the ventilator for an extra couple of days because her family could not accept her death. Her son became belligerent when she died. He accused the doctors of killing her. He insisted that she be kept on the ventilator and said that if they took her off, he would hurt them. So they kept her on, even though she was dead, and tried to talk him down.
I have seen evidence that the hyperbole and hysteria associated with COVID-19 brings out this kind of insanity in some.
People who die with dignity should be respected. They should not be used as political pawns or media tools. Doctors who help those patients should also be treated with respect. Their words should not be taken out of context and twisted for the sake of hyperbole.
It is best for some patients to die at home. Such a death is more peaceful, and they can be with their loved ones. I greatly admire patients and families who understand this and who are able to handle death with courage and dignity.
W. Robert Graham, MD, completed medical school and residency at UTHSC-Dallas (Parkland Hospital) and served as chief resident. Graham received a National Institutes of Health fellowship at the Salk Institute for oncogene research in 1985. He was a professor of medicine at Baylor College of Medicine from 1998 through 2016. In retirement, he enjoys writing and ranching.