Recently, I came across with an article which really caught my eyes. It was written by Ken Murray, MD, Clinical Assistant Professor of Family Medicine at USC. So, now, Its my pleasure to share these story
with you all and do enjoy reading it. Its a long story but I promise, you'll be benefited by reading it.
How Do Doctors Die?
It’s Not Like the Rest of Us, But It Should Be
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.
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.
kumaran nadaraja
