How Doctors Die

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo. To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

I never said that I agreed with what the author wrote. My own mother is currently living proof of why numbers alone don’t tell the whole story. She contracted breast cancer back in the early ‘80s, and the chances they gave her weren’t all that good. Breast cancer treatments weren’t as far advanced then as they are today, and they were talking about her having a 50% chance of survival 10 years later. She went through chemo, and eventually had to have a mastectomy. It was miserable for her, but was it worth it? Well, here we are well over two decades later, and she’s perfectly fine, without any recurrence.

Numbers can be deceiving - true, the chance of CPR actually saving a life is pretty small, only something like 3% of people who have it performed on them survive. But you know what? I’d take those odds over nothing - heck, multiply that 3% by the number of people who have a cardiac arrest, and the amount of people saved each year by CPR is probably in thousands. A small price to pay for a few cracked or broken ribs.

I posted it because I thought it might be of interest here, not because I agreed with all of its sentiments.

This article is little more than propaganda for the death panels that are an integral part of ObamaCare.

Exactly!

Pancreatic cancer is often not diagnosed until the late stages and it's not unusual for a person to opt to not do anything. However, many cancers a fully treatable and it would be insane for someone to not take it.

I'm sorry for your loss. You must still be feeling the pain of loss. She was young and I know how you probably feel, my husband was 51 and had his first and last heart attack. No history of heart problems and he passed on sitting in the shade of his pick up truck while we were putting up hay in the barn....It seems forever my giving him CPR. before the ambulance arrived but we lived in a rural area...

Been there, done that with my dad.

He suffered a major heart attack napping on the couch. I happened to be home that afternoon, pulled him off the couch after calling 911 and did CPR.

They worked on him for over an hour to no avail.

However, I'd try again if I saw anyone have a heart attack.

I'm sorry to hear of both your losses. Some things you never really quite get over.

My mom died from breast cancer which metastasized but she only lasted about a month after diagnosis. It was very aggressive cancer.

Having gone through it both ways, the sudden is a bigger shock and more disruptive, but I found it easier to deal with in the long run.

Thank you for coming on and posting your opinions. People here get very suspicious when someone posts something like this and walks away without responding.

You said this regarding your Mom: "...She went through chemo, and eventually had to have a mastectomy. It was miserable for her, but was it worth it?"

I would say (and I suspect you would agree) that would be her call...my best friend's sister, married with two pre-teen kids, just lost a five year battle with leukemia. In all my years in medicine, I have never, ever seen anyone fight as hard as this woman fought, and she did it for her kids. Just unbelievable. My friend was amazed, astonished and appalled at what she went through to try and beat it. She was hospital-bound and bed-bound for a long, long time. But he says, as miserable as she was, she was willing to endure nearly anything out of love for her two young children. So it was her call, though an extreme one.

To her it was worth it.

There is a time for everything, and a season for every activity under the heavens: a time to be born and a time to die...

My father (terminal cancer) was so afraid of being hooked up to machines that kids and grand-kids took turns sleeping in his hospital room. This was before the living will days...

A few nights before he died there were five or six of us - some sleeping on the flood... A nurse came and said, “Either he's very rich - or very loved”. Amid the laughter were our voices saying, “very loved”. And he was.

Artificially prolonging pain and suffering is unconscionable...

I am going to call BS on this entire article.

Let me guess, he is one of those guys who thinks rationing and Obamacare is just the bees knees.

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That wouldn't surprise me at all.

I don’t have a problem with the observation that physicians and nurses often have the view that when they get near the end, they are much more matter-of-fact about what they specifically do and don’t want.

Many of them have (over the course of their careers) been witness to patients who were tortured by the rigid rules of care of the medical profession or by their family’s refusal to let go long after they should have.

It is a fact of life, anyone who has worked long enough in health care sees it, and any thinking person will take precautions to ensure they don’t end up in that spot.

Is that an area we can all improve on? Absolutely 100%.

Is that an area we want the government making decisions for us in? Absolutely 100% NOT.

(And by the way, this physician who makes these blanket statements about homeopathic medicine and such is perhaps living in a cloistered world view in his corner of California. It doesn’t match what I have seen in the real world.)

First of all please quit putting words in my mouth. Your money, my money and the taxpayer money never entered my mind. I made a statement I believe to be true. You can have your opinion; just don’t tell me you are the only one who has one.

At the very least learn some manners.

Thanks! Don’t stop. It is getting harder and harder to breathe. I live in Memphis, Tn. Today we had a beautiful rare 2 inch snow fall, the second of this season. It was great just to open the blinds and enjoy God’s handiwork.

I think we always have to try when in that situation..We don’t know the future, but can only do the best we can in any situation...like your situation with your father. Its harder when we see someone we love go through much pain and suffering and we cannot do much except stand with them.

My grandmother was felled by a stoke many years ago. My grandfather kept her at home with the services of nurses. She had no movement except her eyes and no special equipment to speak of. She lived 7 more years. We wouldn’t have it any other way. Also, he was wheelchair bound; but drove a car.

I believe everyone has a quality of life. It is how it is perceived.

My parents were both docs and my daughter is a hospice nurse. I volunteer at the local hospice because all too often family memebers are unwilling to be around those who are passing through this veil of tears. I do not advocate one point ot view over the other. I know what I want for myself. I know that for those for whom I am a voice, I make sure THEIR wishes are provided. I am not suggesting that the author has it 100% right, just that those I know in the medical field tend towards minimal procedures at the end of life....comfort care or palliative care is what most of them want. If someone wants everything possible done, good for them. I support their right to make that choice. I advocate for families to be involved and informed that is all. I guess I wasn’t very clear on that. Sorry for the confusion

Roger Ebert has said that he feels he went against doctors’ advice when he first went sick. He’s been honest about that and I do admire his stoicism (if nothing else!)

The Hitchens article is very hardhitting. I had to put my hand over the photo that accompanied it because he looked so...different. His basic theme is: that which doesn’t kill me, makes me WEAKER. He’s truthful in his way as Ebert has been.

Bottom line: everyone faces mortality differently!

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