How Doctors Die: It’s Not Like the Rest of Us, But It Should Be

[Sgent]

by Ken Murray
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.

http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus/
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A great (physician written) article on end of life care.

[pinto]

1. Great, poignant first hand piece. And a look at the broader picture.

I feel it's a discussion that needs to continue across all situations - personal, social, medical, political. And one that needs to accept that there will always be a range of opinion and options.

Thanks for the post.

[hedgehog]

2. Sometimes it's hard to know when to step back and let nature take its course. My mother passed

away last year of nothing in particular, she just got weaker and weaker. She had us take her off the ventilator when it
was clear she wasn't coming home. However - she was hospitalized several times in the previous year when she had breathing problems. Those times she recovered well enough to come home.

[GoneOffShore]

3. My living will is set up so that I'll escape the tubes and the thumping.

And despite the article on Ambien in the NYT, I'm not buying into recovering from a vegetative state.

[Speck Tater]

4. It was different back in the 60's when my doctor died after he fell asleep while smoking in bed.

I was on my way to work when I heard it on the news that firemen found his charred remains among the ashes of his house.

[demigoddess]

5. I've heard that most cancer

patients die of the treatment, not the disease itself. Also not many of the drugs actually work, and poison our bodies along the way.

[alittlelark]

6. 2 that I know of 'survived' chemo

But spent the last 4-7 years of their 'life' in a chemo-fog.

One was a brilliant woman who worked for Forbes and retired to write the "Jemez Thunder"

http://www.abqjournal.com/main/2011/07/25/obit-profiles/jeme-zthunder-filled-with-memories-from-editors-friends.htm

She spent 5 or so years falling over, tripping, occasionally not knowing where she was.

Very Sad.

[jtuck004]

7. Seems to be a little swell of information telling these anecdotes about how

end of life medicine is a waste of money and painful. It seems to have started about the same time I began hearing about the
Republican Die-Early-so-it-will-be-Cheap-on-the-Rest-of-us medical plans and philosophies.

Interesting coincidence. Not wrong, or bad. Just interesting.

I don't necessarily disagree in the cases with the limits the author imposed, because they made good sense, especially if you can go live with a dr who is a good cook those last few months. But people seem to miss the things that make each case unique, so I have little doubt that stories like this feed the thinking of those who want to justify the denial of care to people who really could be helped. Kinda like Reagan's mythical "welfare queen".

A very big part of the problem is the interference of third parties such as insurance, law, and drug makers, and patients who still labor under the delusion that their treatment is between them and a doctor who is only their for the patient's best interests. That physician has multiple legal and governmental regulations, as well as restrictions and direction of insurance and pharma companies.


If we could get those out, perhaps we might find more of the humane treatment the article suggests is possible.

[nadinbrzezinski]

10. I've thought this way since my years in EMS now a few decades in the past

It precedes this new thinking by quite a while. Why? Paramedic... really there are things I will not wish on myself, and I wished I could not on others.

[jtuck004]

12. Oh, of course. I saw instances of this when I worked the streets for 2 1/2 years.

That was a ways back for me as well.

There were always patients for whom the cure was not the answer. Perhaps a few might have wished that we had found them a little more dead so they wouldn't have had to go through as much, because we were really good at getting them into the hospital safe, sometimes in less pain, and still alive.

I bet the majority of them were would have been just fine with the efforts on their behalf, however.

Since the health insurance reform discussion it just seems like there is an increase in the little stories of how death was a welcome relief from treatment, many focusing as much on the cost savings as quality of life, usually anecdotal, and they seem to be accepted much more uncritically. Nearly always the setup is such that the solution of just letting people die earlier, (well, not me, but for you, etc) works so well, and oh, BTW, we gonna save a bundle of $$$.

People should be careful what they wish for.

If the concern is really about the patient, that would be great. But there are a LOT of competing interests out there with an agenda, most of which have not a thing to do with the welfare of the patient. So I try to be careful to be aware of who might profit the most from this.

[a2liberal]

24. yep, articles and attitudes like this are going to make

Insurance companies stop covering important end-of-life care, even in cases where it could make a big difference. Maybe this doc doesn't want the15% chance but i might and stuff like this only gives insurance companies more ammo to deny it to me.

[magical thyme]

29. when I was in school to become a medical lab tech

our anatomy professor, a 36 year nursing veteran and director and director of training at a local hospital, told us if she goes down, step over her body and go get a cup of coffee or something. She has no health insurance. Neither do I. I do have a way to check out painlessly if it comes down to it.

I doubt the timing is a coincidence, but please don't compare what a health care worker who lives it day in and day out says with Republicans 'die on the cheap' plan. The fact is that health care is up for discussion. This is something that needs to be discussed and addressed. So of course it comes up.

As it happens, the hospital where I work serves several nursing facilities and 2/3s of its patients are on medicare. It seems every time we are up on the floor, we have this discussion after. For each the very few people helped by what we do, there are many more for whom we are spending a fortune simply prolonging suffering. That is a fact. We come back down to the lab, look at each other and say, 'don't let that happen to me." My pets get better health care than we do.

You are right that insurance, laws, drug makers all influence the choices Drs. and patients are allowed to make. Humane treatment is possible. It's also often illegal.

"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."

I remember long ago witnessing a woman in her 40s throw a tantrum when her elderly mother's doctor advised not treating a breast cancer. It was a very slow growing type and her mother was 1. far more likely to die of something else long before that cancer went very far, 2. the surgery would be horrific for someone her age

unfortunately a lot of people are not terri

[knitter4democracy]

8. I've been saying this for awhile.

My ex is an internist, and we had living wills that specified exactly what we would and what we wouldn't allow for end-of-life care. Honestly, there aren't many good reasons to run a code, as only 30% actually work (and then there's the quality of life question afterward).

[no_hypocrisy]

9. My father is 88 and a retired physician and has the opposite situation.

He's secretive about it but he's self-medicating. I looked in his bathroom and there are 15 different medications, only four of which were prescribed by another doctor. The rest don't cite a prescribing physician. He can do by being allowed to continue to prescribe despite his retirement and having blank squibs. I'm sure there are drug interactions; I'm checking into that now.

[handmade34]

11. my take on it...

I only skimmed the article... but I think I get the gist. It tells me that physicians generally have a better quality of life overall and that makes for a better transition at the end of it. Education, status, friends, emotional maturity and economic well being all play a part in this play... if only we all had the luxury of those things...


"...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..."

[cbayer]

16. I don't really think that's the take away at all, and suggest you read the article in it's entirety.

[handmade34]

17. I read the entire article

and I still feel the same... maybe I'm not communicating well my take on it... we need open discussions and education (for everyone)about medical issues, procedures and end of life concerns. I have made my decisions, as has my partner.

When my husband became ill, he choose the path at every step and I was with him when he died at home. My step-father also; he wanted no extreme measures and I sat with him (although in the hospital) for his few remaining hours. I maintain that honest discussions about facts/emotions/reality concerning these issues is vital to making us a healthier nation overall...

[cbayer]

18. I am sorry if I offended you. It was not my intent.

My take on this, after hearing the author interviewed yesterday, was that doctors often do what they do because of unrealistic expectations from patients and families or fears of litigation. However, when it comes down to their own lives, they are much more likely to forgo treatment.

I didn't hear it as having anything to do with privilege.

I am so sorry about your husband and completely share your take that end of life concerns must be more honestly discussed.

[handmade34]

20. no offense

just forgot the

not so much privilege, as knowledge (knowledge IS power) and a mature understanding of these issues... that is what is lacking often with non-professionals (and it is human nature to often fear what we don't know/understand)

[tavalon]

13. Please, please read the whole thing

And make your decisions now, while you can. Make sure your family knows what your wishes are. Get a medic alert bracelet that spells out your end of life choices.

[Nikia]

14. My grandfather decided to have emergency surgery in an attempt to save his life

When his aortic anerysm ruptured while he was at a hospital. The chances of saving him were low especially since he was on blood thinners. Despite the doctor's best efforts of hours of surgery, he died anyway. I don't think that it was wrong to try to save his life though.
A couple years later, a local physician had the same problem while she was working at her hospital. Her colleagues were able to recognize her problem and save her. She retired after that, but two years later I saw her walking in a local 5K. I don't think that she would have rather died.

[cbayer]

15. Interview with the author yesterday on SOCal public radio was also very good.

http://www.scpr.org/programs/patt-morrison/2011/12/12/21722/how-doctors-die/

[unblock]

19. about this "breaking... ribs... happens if cpr is done right" thing:

breaking ribs is more likely to happen if cpr is done WRONG (wrong hand position and/or pushing down too hard and/or too far).

yes, breaking ribs MAY happen even if cpr is right, especially if the patient is elderly, but most of the time, broken ribs are a sign of cpr done incorrectly.

cpr training is to ERR on the side of too much force rather than too little force because alive with broken ribs is a better outcome than dead with intact ribs. however, using too much force is still cpr done incorrectly (just not as big a mistake as too little force).

[FloridaJudy]

21. Every single nurse I know

Has at one time had a pact with another nurse to have him/her stand by and make sure that no one tries to intervene at the death bed, and that the morphine keeps coming, even if it hastens the end. We've seen how most patients die in hospitals, and we have no desire to see that happen to us.

A good friend died of liver cancer this weekend. His lover took him home with her, and he died in her arms. Hospice made sure that there were adequate drugs to relieve his pain, though fortunately he slipped into a coma before it got bad. His family cared for him, bathing and turning him, and there was a constant parade of friends to mop the floors and bring food for the caretakers. When he died, his friends and family cleaned him up, and laid him out in state. He was not embalmed. The next day they took him out to a state conservancy area, dug a hole, and buried him in plain pine box. I don't know how they got permission for this, but I bless the bureaucrat who authorized it!

It's always sad to lose a friend, particularly one only in his fifties, but this was one of the kindest, most dignified deaths I've seen: no heroics, no over-priced funeral to bankrupt the grieving. Just a lot of love.

I'm not a mind-reader, but I suspect that a lot of the other mourners had the same thought I did: How can I arrange something like this for me when the time comes?

[DaveJ]

22. They also have access to loads of painkillers!

Ok, I apologize for the irreverence. I'm just assuming they have access to all the most powerful narcotics under the sun, which is this first thing I would turn to.

[supernova]

23. Unethical and illegal

To proscribe your own meds to yourself. That's how you get arrested.

[DaveJ]

26. I'm aware it's not something one would do

who is interested in a lengthy career in medicine, which dying sort of precludes. I'm just saying, they could prescribe opiates to a family member such as a wife or husband, who would surely understand the need to alleviate pain. Doctors would also understand the best dosage and would not have to do any explaining to anyone every time they wanted a refill.

[Warpy]

25. Then again, I know a nurse and doctor who were diagnosed at the same time

with pancreatic cancer.

The doc had the drastic surgery followed by chemotherapy and lived for about 5 months in misery.

The nurse sold her house and started to travel all over Europe. She lived for 8 months, the misery only for the last two weeks.

While I don't find just two cases predict overall survival, I do think it illustrates something about how to proceed with a grim diagnosis and horrible percentages and I know what my decision would be.

After all, I was facing dialysis two years ago and decided it wasn't for me. Quality of life is more important than quantity of life.

I might feel differently if I had small children, so I respect anyone else's decision. I just know it's quality over quantity for me.

[Lyric]

27. I guess I'm the only one who found this article tasteless at best

and offensive at worst.

"Die quick and cheap, please." Right. Easy for someone who's got a nice house, access to the best palliative care, plenty of good, healthy food, good life insurance, plenty of money to spend on your "bucket list", etc. Not so easy for those of us who have no healthcare, poor quality housing and food, and the despair of knowing that even if you sold everything you own, you STILL wouldn't have the money to fulfill even a single dream. It's hard to let go of life when you'll be leaving behind a spouse and kids who are already poor and will only be WORSE off when you're no longer around to help.

I just love these syrupy, romanticized portraits of what a "dignified" death should look like. Maybe the problem is NOT people who seek "too much" expensive, life-extending care. Maybe the problem is that the expense is a factor AT ALL.

[JNelson6563]

28. Very interesting.

I have long had such a plan. I've seen enough of cancer treatments (at least those cases that were far along) that were so harmful I wasn't sure if the cause of death was the cancer or the "cure", as it were.

Since I have no money or insurance, and I surely don't have a doctor, if something like cancer happened to me, it wouldn't be discovered until it was advanced & I would not be able to access treatment anyway. The best I can hope for is for some hospice or something to show pity on me and provide morphine or whatever so my end isn't too horrible.

In the meantime I try to eat healthy and take care of myself to keep the odds in my favor. That's all any American can do, really,when they have no resources.

Julie

[DeathToTheOil]

30. KR