Posted on 12/07/2011 1:11:20 AM PST by JerseyanExile
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.
Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.
It would be interesting to see some actual research into this theory.
Makes a lot of sense to me. Thanks for posting this.
If I found out I was terminal, I wouldn’t do a thing to stop it.
I’d enjoy life, get my things in order and get right with God.
Not necessarily in that order.
Maybe we go into medicine to figure out what death means. Kind of like how the kookiest docs go into psychiatry. I've never met a psychiatrist who didn't have mental illness of some kind.
Some of this article is realistic - futile measures at the end of life often are torturous. Performing CPR on a terminal cancer patient could count among them.
However, I have personally helped bring two people back with CPR and an AED. Both recovered fully and are leading fullfilling lives with family and careers. What is the article suggesting? That I should have left my 37 year old colleague (with two young children) to die on the floor? That I should have allowed my 53 year old neighbor to die on the floor of her kitchen in front of her 16 year old son? Both were apparently healthy before suffering a sudden cardiac event.
The author needs to make a clearer distinction between people whose conditions are long-term and clearly terminal and who need loving care to ease their suffering and those who otherwise in decent health who have a sudden event.
True. From my limited private conversations with health professionals, I also understand that a certain percentage request that when the time comes, the dose of morphine be increased.
Expect to see more and more articles like this as Obamacare kicks in and we are all encouraged to forgo that bothersome end-of-life care to make the numbers look a little better.
That’s what I think. This is an advertisement for death.
That’s what I wasthinking as I read it.
I seem to recal reading about another dr many years ago who chose to fight her pancreatic cancer. I believ she tried a few unconventional treatments like having the chemo put in her abdominal cavity to bath the pancreas in it I thought she was pretty successful. Not sure how long she survived or if she survived. Fighting versus accepting....individual choice....at least for now.
If you’re at that point and there is no real treatment, other than to keep you doped up and unaware of your condition, what are you accomplishing?
Going the route of least treatment can be the most humane, especially if it involves chemo and radical treatments, but every situation is different.
The flip side of this is when a patient is in a coma, and the patient’s stated wishes were that everything reasonable, including life support, be available. This would not include unreasonable major surgeries with a low chance of success.
My experience has been, at least at one major hospital, that when the patient had gone into a coma for only a FEW days, the doctors quickly went death panel on me and pushed to end all treatment.
The patient was my wife, 49, who had a stroke, and a brain tumor was found. The prognosis was bad, but her vital signs were good, and ending her life would have barred any chance for a miracle. Once in a coma, the doctors did pain tests and brain activity tests and found she felt no pain.
Yet they still pushed me to consider her “quality of life”, saying further treatment could be “cruel” and cause her to suffer. I refused to have the breathing tube removed, citing that since she was in a coma and out of pain, that no one could ascertain her quality of life, and that she indeed may be in a state of peace. She passed away on her own a few days later, 4 months ago. If I had followed the insistence of the doctors, I couldn’t have lived with the decision. So there’s many sides to these situations, and it can come down to a specific doctor’s philosophy or the patient’s, vs. the hospital. And sorry for the unpleasant post.
I have already told my doctor my wishes, he said at the time, I feel the same way you do. Just let me go...Its not the governments decision, its the family but mostly the patients decision. If family members cannot respect any decision the patient made, do them a favor and just leave them alone and don't bother to visit, cause you don't love them enough to respect their wishes....
You care more about the pain you will feel when they pass and are not honoring their wishes therefore you are not honoring them.... I nursed both of my parents in my home when they were terminal, For my father is was less than a week and he died....my mother was a little over 6 weeks...I was not going to let them die in a nursing home or hospital. Had 5 kids at the time and found time to care for my parents...they died 10 years apart...
It can be hard for a child to follow the parents wishes, but at least you know you are carrying out their wishes and not doing it on your own..If one of the children doesn't agree with the decision, too bad cause that is spelled out in the will...anyone that makes trouble for those that have been assigned the medical Power of Attorney are automatically cut out of the will...you have to cover all bases and spell out everything in legal document.
I would recommed you don't use just any lawyer, but a lawyer that specializes in that area and can have you avoid completely probate courts...It is the last loving thing you can do for your children. It shouldn't be their burden People should not leave the burden to their children to make that decision. Every person should have a Power of attorney for medical treatment spelled out and signed. Every couple of years I ask the 2 children that have the power if they think they can respect my wishes and if they think they can't, no problem, I will assign another to that job. Legally....
Pancreatic cancer is what Steve Jobs had. He fought it pretty well and lived longer than most do with that disease.
My will says only my wife can terminate my life. No court order, no bureaucrat, no doctor. Only my wife; she’s the only person on this planet that I trust with my life.
Funny how this article ignores the doctors that starved Terri Schiavo to death or the ones that kill babies. I guess they hadn’t seen enough end of life./s
My dentist who is affiliated with Mt Sinai in NYC told me that doctors turn to homeopathic medicine instead of having heart surgery, just because they know the results and what happens during surgery. At the time I thought this strange, but after reading this article,it makes sense. My 99 year old aunt passed away this past Sunday. She would have died four years ago, with dignity. Due to drugs, her illness was prolonged. During this time frame she was miserable as well as those around her.
My guess is, after seeing ends results of their patients, doctors decide how to treat themselves. Also that would show how much of a guinea pigs we are when we enter into the emergency room. It’s ALL about $$$.
Amen! I pray that God gives you strength to walk through this and help others with your wisdom learned and perhaps find joy in life again
Everyone needs to make sure the doctors follow the family wishes...Ihave heard doctors give family's prognosis but never heard one trying to force an opinion and for you, you did the right thing in the choice you made..no one person should try to push a decision on someone that they don't feel is the right decision...good for you being strong....
Your post was very good and sometims when we talk of such things on FR what we say may also be important to some other freeper that might be faced with the same situation
May God grant you peace and healing........GG
Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.