Many Times, Morbidity Can Be Worse Than Mortality

Hesham A. Hassaballa: This is Healthcare Musings. I'm your host, Dr. Hashem Hasabala. Welcome to Healthcare Musings everybody. Happy to have you with me. Okay. The we're in the business in healthcare and especially critical care medicine. The whole point is to delay mortality as much as possible, in especially in critical care. Patients come into the ICU literally trying to die with life-threatening critical illness, most of the time. Most of the time. sometimes there's a need for increased monitoring or something where the patient is not deathly ill and many times, if not most times, people come in with life-threatening critical illness that if urgent intervention is not performed, the patient could possibly, you know, l possibly or likely die. So we're in the business, especially in critical care, of trying to delay mortality. I'm under no delusion or illusion that I can prevent someone from dying forever, or that we can conquer death, or that we can beat death, you know, just like I think it was Benjamin Franklin who said the only two certain things in life is de are death and taxes, right? death is inevitable. It's an it's an an inevitable outcome for everyone whenever, right? And I have seen in the ICU that if someone is is is going to die, if it's their time, no matter what I do, despite all the effort that I exert, they're going to pass away. I saw that in COVID all the time. And there are other times when people who I think are going to die live, right? And it's not I'm not trying to prevent it or I'm not trying to hasten death. I'm just thinking, okay, I'm doing everything I can and I don't think this patient's gonna survive and they do. I saw that in COVID too. Someone I sent upstairs to die on hospice and she woke up and left and we clapped her out of the hospital. I saw that during the pandemic as well. And so I'm under no delusion that I can that, you know, that we can have people live forever. It's not gonna happen. It's not gonna happen despite what many people think. At the same time. We are in the business of trying to delay mortality. And that's when when I think about that, a lot of times there's morbidity associated with trying to delay mortality. And that morbidity is sometimes, if not many times, worse than mortality. You know, we look at a clinical trial, and I get it, I totally understand. If you are testing a new therapy, a new drug, a new device, and the the group that is randomized to the therapy that's being studied causes more deaths than the placebo or then the control group, you don't want to use that drug or or device. That totally makes sense. You don't want to introduce a treatment that's going to kill more people than it saves. That totally makes sense, right? And so I get why you want to test mortality. In a clinical trial. And a lot there are sometimes therapies, treatments, things that are studied where they don't have any improvement in mortality, right? And that's the headline. whatever blank treatment does not improve mortality, right? And if it improves morbidity, if it lessens morbidity, if yes, people don't necessarily die more or less from say septic shock. And this therapy allows less of them to have renal failure, less of them to be on the ventilator, less of them, you know, to stay sh longer in the ICU. I think that's not necessarily a bad thing, right? If you can lessen morbidity without necessarily prolonging decreasing more prolonging life or decreasing mortality, that may not necessarily be a bad thing. You know, if you have a cancer treatment that okay gives you four months of life longer, but in those four months, you're miserable the entire time, w I don't know. I don't know if a lot of people would want it would want that. I I don't know that I would want that, right? And I I I talked about that with Dr. Scott Matson, right? Yeah, I think a lot of people wo would rather live six months less but have meaningful quality of life rather than six months longer with getting this chemotherapy drug or whatever drug or treatment or therapy, but they're miserable the entire time. Right. now I'm gonna qualify it. My my daughter, any god forbid, anyone's child gets cancer. And of course, any parent is gonna fight like hell for their kid to try to prevent, you know, to try to treat the cancer. And at the same time, looking back with the withn with my daughter, she had diffuse large B cell lymphoma. She was miserable. I know now, the whole time she got chemotherapy. And we were back and forth from the hospital. Every time she'd get in the she'd be in a week in the hospital to get the chemo and then she'd be at and she'd poop blood and then we'd have to go back to the clinic to get platelets and She was in pain. she the poor thing was miserable, miserable the whole time. Right. And so the the the l a lot of this is what we talked about last time about the perfect being the enemy of the good, right? Sometimes morbidity is worse than mortality. Like l give you a very common example. You have c you have cardiac arrest, right? Somebody has cardiac arrest. And we're doing CPR and we're giving drugs and we're doing everything right. And the longer you go without perfusion to the brain, the more the more damage occurs. It's and even with good CPR, i i i if it's going on fifteen, twenty, twenty-five minutes, even with with good CPR, whatever we do externally, even with a Lucas, it's not like the heart beating by itself. It's not. It's just not. Right. And so yeah, e we can bring the heart back, right? The heart starts beating again, right? And the blood starts flowing again. And now you have Permanent brain damage. You have permanent organ damage. And now the patient is left machine dependent. You know, they they need a ventilator to breathe. They need a a tube in the throat because they're not awake enough to clear their secretions and maintain a patent airway. Their kidneys likely are failing. Now they're on dialysis. They can't eat because they're completely obtunded and now they need to be fed through a tube. So all that is morbidity. It's not mortality. We save the mortality, right? That that's to me, to me, that's worse than mortality. And I've said this to patients and their families all the time, especially the families. I tell them there are things that are worse than dying. There are a lot of things that are worse than dying. Especially when we're facing the imminent death of their of their loved one. There are things that are that are worse than dying. Now we This is not this is not to say, and I want to qu you know, make sure this is loud and clear. This doesn't mean that there's no point in trying to prevent someone from dying from critical illness. That I'm that's why I'm a doctor. That's why I'm a critical care doctor, because I love trying to intervene and helping someone. And thank God, thank God, we are mostly successful. Our mortality rates are are in the minority, right? And so we're successful. People come. deathly ill, we treat them, we're we're we know what we're doing and they and they survive. And then they come back and thank us and that's amazing. Or when we see them, even if they don't come back and thank us, it's great when they do. And even if they don't, when we see them leave the ICU alive and hopefully well and thriving, that's amazing. That's oxygen for me. So I don't want anyone to think that there's no point. Why am I in the b that's why I'm in this business. At the same time, I know that the perfect, like we talked about before, can be the enemy of the of of the good. Yeah. Okay, we staved off mortality, but we left a patient completely machine dependent, completely c comatose, being th kept alive on machines. A lot of people, there are some people who want life for the to the very end. Doesn't matter. There are some people like that's fine. If that's what their goal of care is, those are their values and preferences. I respect that and I will do that for them because that's they're my patient, they're my client, and I will do I will take care of them within their w within their values and preferences. That's it. I I from all my years of practice, that's a that's a minority of people. Most people would want quality of life, not necessarily quantity of life. Me same with me. When I told the oncologist before we started chemotherapy with my daughter, I told her I know she's sick. She has nodes everywhere, her spleen is big, she can't breathe. I get it. But you know what? She's happy. And I want quality of life for her, not quantity necessarily. And I knew we were facing a life-threatening condition. And she said, I totally understand. And so most people when when you bring it about, either they want quality for me too, for me. Quality of life, not necessarily quantity of life. And so while, yes, I'm in the business of trying to stave off mortality, it's why I became a doctor and a critical care medicine doctor. And I will do it every time. And I will fight like hell every time if my patient wants me to to try to stop mortality. And delay it. At the same time, we have to keep in mind and and explain to patients and their families that sometimes morbidity is worse than than than mortality. And if we cause worse morbidity for someone, then more mortality is permanent, yes. And a lot of times people who have been suffering for cr for from from chronic illness for a long time, you can the family say they're tired and they just want to rest. Sometimes mortality brings rest, right? Morbidity can Can bring a lifetime of suffering. They're alive. Yes, they're alive, but they are suffering. And I I can't tell you how many times patients' family say, They're suffering. They're tired. Even my daughter, she told me, Baba, I'm tired. I want to go home at the very end. Right. So sometimes morbidity brings about can bring about a lifetime of suffering. Where mortality, while sad, can bring rest to the to to the to the patient. We just have to think about that and keep that in mind and help our patients make the make the decision. Help our patients tell us what they want for us to do and their families. They we need them to get from them what does their patient want us to do? And if they can't speak, then they can speak for them. You know, if they saw themselves in the bed hooked up to machines, what would they say? That's the way we answer that we asked the question. We talked about that last time. Because Because a lot of times morbidity is worse than mortality. Anyway, thanks so much everyone for your time and attention. And I'll see you next time on Healthcare Musings. Thanks for listening. Healthcare Musings is a production of FaithfulWord Media. Sign up at drhasabala.com to get every episode delivered directly to your inbox. And please don't forget to give the show a five-star review. Thanks so much.