Seminars in Nephrology
VOL. III, NO. 2 JUNE 1983
The Ultimate Problem
Mr. Lincoln (not his name) was a 54-year-old man with metastatic prostatic cancer and chronic renal failure. He had been on dialysis for a number of years and, for a while, had done well. When the diagnosis of metastatic prostatic carcinoma was made, he underwent a bilateral orchiectomy. He refused chemotherapy, however. For a while, he continued to do well despite the obvious presence of cancer. Another hospitalization was required to treat congestive heart failure. During this time the patient lost 30 lb of edema as a result of vigorous dialysis therapy. He had some pain from his tumor, but in general was reasonably comfortable.
Two weeks after his discharge he was readmitted because of abdominal pain. His tumor mass had obviously enlarged. In addition, he had developed an abdominal wound which appeared to be draining feces. Further evaluation demonstrated a fistula between the rectum, the bladder, and the skin. Medical oncology was consulted but felt there was no effective treatment they could offer this man. The patient, who was highly intelligent and in complete possession of all his faculties at all times, was apprised of his situation. He understood that he had an untreatable cancer and that all we could offer was relief of pain. We asked if he would be happier if he were discharged from the hospital with an appropriate prescription for pain relief. He stated that he would prefer to remain in the hospital. We readily agreed to this and then discussed the matter of continuing his dialysis treatment. We told him that, if he wished, we would continue to dialyze him as vigorously as we had in the past, but that if he felt such treatment would only allow him to die a painful death (with the passage of each day his pain became progressively severe) we would stop dialyzing him. We further explained to him that he could take as much time as he wished in making a decision and that regardless of the decision he made he could change his mind. He inquired as to how long we thought he would live and in what condition if we continued dialysis and asked the same information if we were to discontinue this treatment. We gave him our best estimate while explaining that it contained a considerable margin of error.
He thought about his options for about five days, and then told us on rounds that he thought he would prefer to stop dialysis. We told him again that if at any time he changed his mind we would restart his artificial kidney treatment. He said he understood this and thanked us for our concern.
Mr. Lincoln, who was a very proud man, had three children who were very fond of him. Despite this he had avoided them during this terminal phase of his illness. While never expressed, we felt that it was his desire not to be a burden on his family. From talking to his children, it was quite obvious that they did not consider him a burden and wished to spend more time with him. We asked him if he would mind if we called them and informed them of his decision to stop dialysis. He said he had no objection. We called his children and they immediately came to the hospital.
During the last few weeks of his life, Mr. Lincoln had formed an especially close relationship with one of the medical students on my service. He told the student that he would like to have a beer with him. He also expressed a wish to have a bowl of coconut ice cream. The student obtained the ice cream and two cans of beer and they spent part of a Saturday afternoon together drinking the beer, eating the ice cream, and talking. Mr. Lincoln’s daughter was in the hospital that day and asked if she could spend the night with her father. This was arranged and she slept in his room that night. During the evening, the house staff asked Mr. Lincoln if there was anything that he would like to have. He said that he would really enjoy a glass of orange juice. This was obtained and he drank it with relish. Shortly thereafter, he went to sleep with his daughter in the room. At 6:00 in the morning the nurses noted that he was dead. It had been three days since his last dialysis. On Saturday morning, his serum potassium was 6.7 mEq/L. While we can’t be certain, it seems highly likely that Mr. Lincoln died from the cardiac effects of hyperkalemia. The source of the excess potassium, of course, was dietary.
In thinking about Mr. Lincoln, a number of questions keep recurring. I have the answers to none of them, but they are important questions nonetheless. Did Mr. Lincoln die as the result of euthanasia? Did he commit suicide? Did he die from natural causes? Clearly, if he had not stopped dialysis and had not consumed foods high in potassium he would not have died when he did. As I have said, he was highly intelligent, and while we did not discuss this, I have no doubt that he was aware that orange juice is high in potassium. I know we were also aware, though we were not thinking about that when we gave him the juice. If we had given him potassium intravenously, that clearly would have been euthanasia. How different is it to give him food and drink high in potassium when he had no renal function and was not receiving dialysis treatment? Giving him cyanide by mouth would have been legally and morally wrong, but giving him dietary potassium seems to be all right.
Last, given that Mr. Lincoln had untreatable cancer, he was in a sense fortunate to have chronic renal failure. He had the option to stop dialysis and die peacefully and at a time of his choosing. If he had had metastatic carcinoma without chronic renal failure, his death would have taken a considerably longer time and been associated with much more pain than he experienced. Regardless of his wishes, we would have only been able to treat his pain while waiting for his disease to kill him. The problems I am raising are as obvious as their solutions are elusive. We can relieve pain and suffering, but only to a point. The patient can, in essence, take his own life when he has widespread cancer if he is fortunate enough to have a disease like chronic renal failure. He cannot take it by a more active course. I cannot even begin to competently discuss a problem which has troubled theologians and philosophers for centuries. But the distinctions between what is permissible and what is not sometimes appear precious. All I do know with certainty is that we helped Mr. Lincoln and that he knew we were helping him and was grateful for our efforts. I feel good about the way things worked out.
Kurtzman NA: The Ultimate Problem. Sem Nephrol 3:75, 1983.