Last week, a 75-year-old man was admitted to Aarhus University Hospital in Denmark only to learn he had days, or possibly hours, to live.
Carsten Flemming Hansen had internal bleeding and an aortic aneurysm—a bulge on the main vessel that delivers blood throughout the body. The hospital staff knew he was too sick for surgery, and it was only a matter of time before the bleeding ended his life.
So, instead of continuing treatment, they offered Hansen a different way to spend his last moments. They wheeled his bed out onto a balcony so they could honor his dying request: to smoke a Green LA cigarette and drink a glass of cold white wine. He got to watch the sunset with his family.
The hospital shared a photo on its Facebook page (which the family presumably gave them permission to do) writing that, even though there's no smoking in the hospital, the nurses and family agreed that Hansen's last wishes were more important than treatment and smoking rules. "This is his moment and his farewell to life," Inge Pia Christensen, the nursing director at the hospital, told a Danish news publication, per a translation.
The photo of Hansen with his wine and cigarette quickly attracted attention on social media; it's been shared more than 5,000 times. Commenters praised the staff for defying the no-smoking protocol to allow Hansen a "dignified" death, while also lamenting how if Hansen had been in a different country, the rules may not have been broken.
"Wish our hospitals here in Australia showed that kind of humanity," one commenter wrote.
"In Italy, it would never happen."
"I would like to think that in America we would do them same, I am not sure," another said.
Would this happen in the US? As early as 1998, 96 percent of hospitals complied with a smoking ban standard set by The Joint Commission, which accredits and certifies healthcare organizations. Today, some hospitals, like those in the University of Pennsylvania Health System and the Cleveland Clinic, won't even hire employees who smoke.
But Hansen's story is less about smoking and more about end-of-life care: providing a patient with whatever specific thing makes them comfortable in their last moments. In that regard, we're not so far behind.
"I honestly didn't find this surprising or unusual at all," says Craig Blinderman, associate professor of medicine and director of the Adult Palliative Care Service at Columbia University Medical Center. "We do this kind of stuff all the time."
Arthur Caplan, head of the division of bioethics at New York University Langone Medical Center, not only agrees, but says he's personally helped his patients acquire contraband. When a family member was dying of colon cancer—and given strict orders to not eat or drink—Caplan had no qualms with bringing him a beer. "I got a beer and snuck it in, and let him have a sip," he says. "It was definitely against medical advice; his stomach was blocked. But he just had a sip, and it meant a lot to him."
Caplan says it's common for hospitals defend the rights of sick patients in their 70s and 80s to smoke. One Philadelphia hospital built an enclosure for smoking veterans so they could light up in the winter without having to go outside.
Caplan has seen prostitutes brought into nursing homes to visit lonely patients, and nurses that look the other way. Palliative care wings often have therapy dogs, violating the 'no animal rules,' and Blinderman knows of some patients who've snuck their own pets in for company. Caplan says he's seen patients visiting their pets in hospital lobbies. Sometimes nurses and doctors risk their patients' lives, and break the rules, to wheel them outside into nearby woods or a field so they can be in nature one last time.
"I think health is—obviously—good and doctors and nurses and administrators are trained to aid health," Caplan says. "But at some point, other values start to creep in. You have to make adjustments for quality of life, or preferences, or just plain enjoyment. Even if fleeting, it takes precedence over what's best for your physiology or rules. I don't buy the mentality of, 'we're going to be medical prudes until the end.'"
Blinderman says that at Columbia, they might not let a patient smoke in the building, but would happily take them outside—and often do. But he says that in almost all cases, accommodations can be made for many requests. "There's a kind of leniency that may develop around rules and how we approach them once they decide on focusing on comfort care," he says.
One case that sticks in Caplan's mind is when he found a place in a hospital where a patient's family member could sacrifice a chicken. The sacrifice was a healing ritual for their religion and, while definitely against hospital rules, Caplan decided to help.
"I worked with him and Patient Relations, and he killed his chicken," Caplan says. "[It] didn't seem to be consistent with sanitation rules. I'm not sure I can condone the killing of the chicken. But that's his culture, and it gave him some peace of mind that his relative would get better. I'm not saying we have to set up chicken-killing facilities at every institution, but in this instance, it just seemed to make some sense, and we worked it out."
The real question, Blinderman says, is not if our dying moments in a hospital are cold, cruel, and hooked up to machines, but rather, "Why do people have this assumption that it's like that?" Perhaps it's because they had a negative experience with a friend or family member or they have misconceptions about what's possible, he argues. "People don't want to linger in some hospital setting or hospice setting in a disabled state. That this post went viral, it's interesting. It shows that people are concerned about their own end of life."
It's true that more of us now die in hospitals than at home, and this may conjure images very different from watching the sunset with your family, cigarette in hand. About 80 percent of Americans would prefer to die at home, but only about 20 percent do. The rest die in nursing homes (20 percent) or hospitals (60 percent). A 2013 study in JAMA looked to see where Medicare patients spent their final days, and found that while an increasing number died in hospice, more than 28 percent of hospice patients were only enrolled for three days or less.
There may be some reason to be wary of dying in a hospital. Studies have shown that people who do receive more intense tests and procedures. Research by Arcadia Healthcare Solutions showed that it costs more to die in a hospital than at home, in hospice, or in a nursing home, and that patients in hospitals were billed for many more medical interventions than those who died elsewhere.
But is this out of lack of compassion or compromise from the doctors and staff? It may just be that we don't talk enough about our final wishes. Only about one in ten doctors say they speak to their patients about death, and if doctors and patients did talk, they might find some common ground.
A 2011 essay written by a retired family practice physician called How Doctors Die showcased how doctors, when faced with a terminal diagnosis, choose to skip treatment completely, and spend their last days with family at home. (It's now being incorporated into medical school curricula.) A Stanford University School of Medicine study came to a similar conclusion: 88 percent of doctors would forgo resuscitation and aggressive treatment if they had a terminal illness.
"A big disparity exists between what Americans say they want at the end of life and the care they actually receive," the authors wrote. "More than 80 percent of patients say that they wish to avoid hospitalizations and high-intensity care at the end of life, but their wishes are often overridden."
Why? Both doctors and patients want similar things: dignity, family, lack of pain. The problem, Caplan says, is not that we refuse to accommodate those wishes, but that unlike Hansen in Denmark, we're not verbal enough about them.
"Sometimes it's important to ask," he says. "In this case, the guy brought it up. In other cases, people may not want to be a burden, and not say what they are wishing for. They might say, 'you know, I'd really like to shut that damn TV off' or 'get a full night's sleep without getting my blood drawn.' Their wishes aren't necessarily what we might think of."
Like a glass of wine, or a cigarette.
"They're the small, simpler things," Caplan says.
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