It seemed a befitting end to my medical school career. The patient was dying. Late 70s, history of Stage IV cancer, now with sepsis and respiratory failure. All attempts at weaning the patient from the ventilator failed. The patient's heart failure worsened the situation as fluid backed up into the already damaged lungs. Then the kidneys began to fail which was the tipping point. As I said, the patient was dying. The family had been presented with end of life care on multiple occasions. They refused. They wished to keep going. It was clear that the patient was in pain - groaning, writhing, restless, high heart rate. But everytime we sedated them more, the respiratory condition got worse.
So on my last morning rounds of medical school, I stood tall, my voice loud so the entire group could hear and began, "just because the family wishes to keep fighting does not mean we lose sight of the obligation to the patient, who happens to be in pain from bone metastases. It is clear that with multiple failures at weaning her from the ventilation, her respiratory failure is not improving. In fact, it's getting worse judging by her compromised heart function, chest x-ray, the blood gasses, and her worsening acidosis compounded by renal failure. What's the harm in keeping the patient comfortable? She is dying either way. She might as die without pain." The attending nodded at me and told the nurse to bump up the fentanyl.