Published On September 22, 2005
FOR MORE THAN 40 YEARS, ever since serving as an intern at a cardiac care unit in the Bronx, where he was called upon almost daily to counsel the dying, psychiatrist and Jesuit priest Ned Cassem has dealt intimately with death. In 1973 he established the Massachusetts General Hospital’s Optimum Care Committee—the first ethics consultation committee in North America.
Q: What’s a typical case for your Optimum Care Committee?
A: I’m not sure there is a typical case, but the common denominator is conflict. Take, for example, an argument with the son from hell. He comes from the opposite coast. He hasn’t been part of his mother’s life for years. They’ve had a horrible relationship. Basically, he hates her. Now he says, “Do everything, doctor. I demand you do everything!” So I tell him, “She weighs under 100 pounds. She has metastatic disease in her ribs and sternum, and it may not be in her best interest to resuscitate her.” Often families don’t know that resuscitation may mean crushing the sternum so hard that the ventricle pushes blood out into the aorta. It may mean breaking ribs. That’s brutality.
Q: What happens then?
A: I ask the son in my most serious voice, “What do you have against your mother?” That usually gives him pause. But if he doesn’t back down, I tell him “we don’t do this at the MGH.” My responsibility is always to protect the patient.
Q: Who actually decides what’s best for the patient?
A: If the family and the medical team disagree, the Optimum Care Committee meets with the doctors, the people on the floor taking care of the patient and whoever is complaining. It could be the entire family or just the son and his lawyers. Then we deliberate and make a final decision. We won’t transfer the patient to another hospital. The family can go to court if it wishes, but our obligation is to stand up for the rights of the patient.
Q: Do you sometimes feel like you’re playing God?
A: No. I’ve got the expertise of the whole hospital behind me. I’m just taking the advice of experts—a neurologist or a pulmonologist—and using their judgment to make a logical recommendation. They are a lot more objective than the son from hell.
Q: Are doctors better at handling death and dying now than in the past?
A: No. They didn’t tell patients they were dying 20 or 30 years ago—and in most cases they’re not telling them now. But patients have gotten much more savvy about disease and death. They can read the doctor’s gestures and know whether their disease is curable.
Q: You have a rating system for death. What makes a death “beautiful” and what makes it “bad”?
A: It’s beautiful when it’s meaningful—when the family is there and they all have their hands on the patient. They may light candles; they may hold a vigil. They may have a clergy person preside. It’s a type of death in which all present can be proud of their roles when they look back.
A bad death is one in which the dignity and the respect of the patient have not been honored and the patient has been allowed to suffer. To try to keep a dying patient alive puts a burden on that person that is much greater than the benefit of inappropriate treatment.
Q: Another rating system led you to create the Optimum Care Committee.
A: I modeled it on a group that did a simple experiment on rounds every day. The cardiologist would ask the head nurse, the residents and the attending physician: Does this patient require A, B, C or D? A is the works; anything goes to save him. B is still the works, but we will see how he does today. C means some treatments are outlawed, like CPR or putting the patient on a ventilator. D means stop everything now and let him die a comfortable death.
Q: What have you learned from your decades at the bedside?
A: That death actually has the secret of life in it. If you confront death with somebody you love who is dying, out of that will come learning that transforms your life. It leaves you stronger, braver, calmer.
Q: You don’t think death is depressing?
A: I think it’s inspiring. It doesn’t depress me. It makes me sad, but being sad is different from being depressed. There’s a ton of sadness, which is a measure of how much the person was loved.