The highest form of patriotism

Historian Howard Zinn said "While some people think that dissent is unpatriotic, I would argue that dissent is the highest form of patriotism". I would go further to say that without dissent it is difficult to clarify one's thoughts on a subject. Take my post about killing grandma, for example, which has been making rounds this week -- kevinMD, doc2doc, Leftrightcenter, to name a few blogs that have posted it (or my edited version of it). Much of the feedback expresses agreement with the sentiments. However, it is the dissenters that are driving me to develop more clear thinking on the issue, and I thank them for that.

Some of those who disagree do so for two reasons: 1). They feel that the government does not belong in planning healthcare decisions, and 2). Some feel that intensivists are "glass-half-empty" people, and tend to exaggerate the gravity of every situation, conveying muted enthusiasm for "everything". Some of the commenters even suggested the I was a DNR (do-not-resuscitate) order hound and should not be listened to for that reason.

In fact, it is good to have dissent electronically -- it minimizes the opportunity for ugliness that has arisen in town hall meetings, and, if done civilly and without personal attacks, allows for clarification of everyone's valid objections. It also gives me the chance to respond thoughtfully rather than with a knee-jerk.

So, here are my measured responses. As far as the government being involved in bedside decisions, that is not my understanding of the bill. The provision for a physician to conduct advanced directives planning is there to establish a reimbursement mechanism for thoughtful care, rather than what exists today, procedure-oriented care. As for intensivists' attitudes, that is just not borne out in the literature. In fact, we are as bad at giving realistic predictions as any other specialty, and we are never willing to err on the side of withholding care. Another very important reason for advanced directives is that research indicates that family members usually will opt for more aggressive measures for their loved ones than they would for themselves in a similar situation. So, leaving these decisions to families is likely to result in more painful and useless interventions than the patient, were she able to express herself, would wish for. Not to mention the lasting pain for the family.

In the ICU I have held many hands and wiped many tears. I have had the privilege of offering soothing words and sitting quietly with grief. Most of these families would not have chosen to go through the agony, had they known what "everything" entailed, or what horrible life-altering decisions lay ahead. Feel free to disagree with me -- after all, dissent is patriotic. But if you know anyone who has gone through an ordeal like ones I am describing, ask them about it, listen to them respectfully, and draw your own conclusions about the virtues of advanced directives.