Comfort

My dialysis patient was dying. The fluid drained from his abdomen was red, and his lips blue. We were discussing the ways to keep him comfortable during the morning round. "Should we stop escalating the antibiotics?" I asked.

Absolutely.

Every team member agreed and I leaned forward to write down the decision. I glanced at the consultant next to me and didn't have to wait long to find out he frowned at my handwriting. So, did I write too much? Probably yes, a small voice inside me told me, but it's impossible to know for sure.

To test the water, I quoted the recent New England Journal of Medicine review article on comfort care for patients dying in the hospital, "I recalled a recent piece of article supporting explicit orders to promote comfort and prevent unnecessary intervention, rather than simply writing an order "comfort care." It isn't easy for our interns to second-guess what we have in mind, say, in case our patient's blood pressure plummets tonight. What do you think?"

My consultant replied, "Not really, because they have to learn. Not just to follow." "But surely," I had to politely disagree, "the very fact that interns need the chance to learn doesn't mean we should write a vague term. Learning is a matter for the interns and ultimately the residents. Unnecessary suffering is a matter for the patients, in this case a dying patient. The two things should be kept rigorously separate."

We didn't have the right answer to the question, but I dared not to argue too much. To my mind, there is no right or wrong answer. I'm not arguing that once the team decision has been made and stated, there is no need to think and rethink, as if this is a gospel. But my argument is that at the very least a decision should be clearly spelled out for others to follow and, if necessarily, revised.