Code Status II

This is a continuation from yesterday's post. I'm not even sure the ideal code discussion is possible. The ideal setting is for a patient and her primary care physician, who has known her for a long time, to have an engaged two-way conversation regarding how she envisions the end of her life. It involves presenting the data in an unbiased manner and exploring how the patient's values and underlying conditions intersect with the practicalities of CPR, intubation, etc. But how is someone to know what she'd like at the end of her life (if she were not there yet). Certainly I think I would not like aggressive resuscitation, and yet, I can't imagine at all what it would mean to be critically ill and at the brink of such an intervention. I just don't know. Should code statuses be a wish we have when we are well? Or something we finally understand when we are sick? How would you like to die?

This fundamental ethical question may be as important as how we would like to live. But none of us (possibly? presumably?) have died before, and in much of the literature of death and dying (all of my posts are labeled "Death"), the talk of "dying with dignity" and "the good death" are all extrapolated from observing and interacting with loved ones in that situation. But how we feel about our death now, when we are healthy, may be different than how we feel about it when we are in extremis. Which is more reflective of our core values and identity? I don't know how to answer that question.

Most of us may imagine that at the end of life we would not want to overdose on pain medications to commit suicide. But how many cancer patients have I seen who beg for relief of their unrelenting pain? How valid are their wishes? When one is in pain (or depressed, or nauseous, or in a psychotic break), one says things that are irrational, unreasonable. Perhaps their wishes for death are tortured out of them. But on the other hand, I can't imagine how much pain that end-stage cancer patient is in. How could I know that I wouldn't ask for narcotics to kill myself? How could I be sure that my opinions now are valid in circumstances I've never experienced?