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    Saturday, May 23, 2009

    Should End Of Life Patients Smoke?

    I’m in complete sympathy with Peter A. Ubell, MD ,director of the Center for Behavioral and Decision Sciences in Medicine at the University of Michigan who writes that “Eighteen years out of training, and I still find myself struggling to understand the moral imperatives of medical practice.”

    “Not long ago,” he relates, “as part of my hospital duties, I cared for a man who could no longer swallow. This dysphagia was his only medical complaint, one that had sneaked up on him over the course of a month. He simply couldn’t find the muscular strength to propel food and liquid down to his stomach. After some investigation, the medical team discovered he had metastatic lung cancer. That explained the dysphagia: cancer had stimulated his immune system to attack his swallowing muscles.

    While the cancer was incurable, we hoped we could slow its progression and give him a few extra months of life — small solace for a man in his mid-50s with a loving wife and several children ready to start new families, but the best we could offer. On rounds the morning after he received a feeding tube, I stopped by to see how he was doing — checking his abdomen for signs of infection and, more important, assessing his fragile mood. I tried to keep things upbeat, making small talk while examining his belly. But something about his response, and the look he gave his wife, was troubling.

    I looked up and asked him how he was feeling, keeping purposely vague about whether I was posing a medical, or a social question. His wife replied— angrily. She lashed out at her husband for having sneaked off that morning for a cigarette. He glared back and told her to mind her own business. She looked toward me for support — I was the physician, after all — and I found myself in a common medical quandary.

    According to this new paradigm of preference-sensitive decision-making, doctors like me shouldn’t tell patients what to do (Take your pills! Stop smoking!), but rather should educate our patients about the risks and benefits of their options. So going by the book, I should have informed my patient about the pros and cons of tobacco. But I couldn’t stand by, in the role of a dispassionate educator, and let this man hurt himself. Instead, I felt compelled to give him advice that would promote his best interests.

    I advised him to smoke. Then I turned to his wife. “I know that you are trying to keep your husband from smoking because you love him and don’t want him to get sicker, but those cigarettes aren’t going to hurt him now. If anything, they’ll help him relax.”

    Medical decisions these days are increasingly recognized as being more than simply medical, with the right choice depending in part on the patient’s preferences. My duty as a physician, says Ubell is to improve my patients’ lives. And if I can do that by sharing my perspective with them, however strange or uncomfortable it may sound, then that is what I must do. Even if it means encouraging them to smoke.

    This anecdote brought me back a few decades when my father was also at his end of life. He was in his room at Johns Hopkins Hospital for several weeks suffering from Chronic Obstructive Lung Disease [COPD]-after a lifetime of cigarette smoking-Lucky Strikes, unfiltered to keep the taste strong. Every breath was an effort. But he managed to breathe “better” while smoking, he said.

    I was a resident physician at the hospital which made it easier to visit with him 3-4 times per day. Oxygen tanks for his oxygen treatments every 2 hours were in his room- so smoking and matches in his hospital room were out of the question.

    My father understood this.

    So when no one was looking-or he thought no one was looking-- he wheeled his chair into the visitors lounge. His engaging good nature always managed to get him a cigarette- from either a patient or guest. Today smoking is banned in offices and workplaces and even banned in many bars but those were the days when smoking was not banned even from hospitals.

    He smoked in the hospital visitors’ lounge-but quickly put it out and hid it when nurses were close. One nurse whispered to me about his secret violations of the medical regimen and insisted that I stop his smoking or she would tell his pulmonologist who happened to be my boss.

    What was I to do? Smoking is contra-indicated in everybody-especially those ravaged by the terrible effects of tobacco in the lungs. But was cessation of smoking now going to help him after 50 years of the habit resulting in death approaching in weeks if not days?

    My duty as a physician is to improve patients’ lives. Moreover, like Ubell strange as it may sound, even if it means enabling them to smoke.

    I made the same decision. In fact, I aided and abetted him by getting him an occasional cigarette and wheeling him to the outside deck of the Marburg floor where he could privately smoke in peace in the early Baltimore Spring.

    He understood and was grateful. His eyes told me even though he would not say it for fear of incriminating me in the crime.

    His pulmonologist also understood. He never mentioned anything about it to me.

    My father died later that spring.

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