If Your Heart Stopped Tonight

An ICU physician on taking time to discuss with patients how they see their final days
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Dr. Ed Friedlander displays his tattoo with a medical directive to not use CPR, in 2011 (Charlie Riedel/AP)

Nearly 15 years ago, the management of a large company had a novel idea about how to encourage its employees to enroll in 401K savings plans. It wasn’t by creating more attractive savings schemes, but by automatically enrolling their employees into the same plans they’d otherwise ignored.  The employees could opt or change plans, but few did.  Facing a complex decision they were poorly equipped to make, people went with the default option.

Those who study behavior have long recognized the privileged place held by the default—the action taken if a person fails to make a decision. The rules are true in savings plans and car insurance and organ donation. But we consistently and—research now suggests—wrongly, assume that when people are posed with questions about death, decision-making should be inherently different.

My patient was nearly 80 years old and had lung cancer and a pneumonia. I had been a doctor for about a month. It occurred to me one evening, watching her oxygen levels plummet with each paroxysm of cough, that I should probably ask her what she’d want us to do if she got sicker.

“Some patients ask us to do everything,” I told her. “That means electrical shocks, a breathing tube, the ICU.  We could do that. Other patients tell us that they don’t want any of this and would prefer just to be comfortable.”

She finally answered: “Well, I don’t know. If my heart stopped tonight? Do everything.”

I made a check mark on my to do list for the evening and thought about the way it feels when ribs break under your hands during chest compressions.  

I know that my intentions were good. After all, our intentions generally are. But perhaps our assumptions are flawed, and this is what gets us into trouble. At the University of Pennsylvania, Dr. Scott Halpern, an assistant professor, runs a program that aims to improve end-of-life care by studying how people make decisions. His group recently tested the idea that end-of-life decisions could be influenced by the way options were presented.

They asked more than 100 patients with terminal diseases to fill out one of three advance directives. Two of the sample advance directives had one option already checked off. This was the default—in one the default requested doctors to focus on comfort, the other set asked to extend life at all cost. In either scenario, the patient was free to choose a different option.

My conversations have always assumed that regardless of how I present the information, people should be “immune,” as Halpern says, to the types of bias that plague other decision-making arenas. But that’s not the case. Patients were more likely to elect to receive comfort-oriented care at the end of their lives if that was the default option they were randomly assigned. The default options also changed people’s decisions about chest compressions and breathing machines and feeding tubes.

The patients weren’t any different but the default options were and thus, so was the care these groups said they’d want at the ends of their lives.

Presented by

Daniela J. Lamas, MD, is a pulmonary and critical care fellow at Massachusetts General Hospital. Her work has also appeared in the New England Journal of Medicine, The New York Times, and NewYorker.com.

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