Before we 'kick
the bucket', maybe we should read this…
How Doctors
Die...
Many doctors
make dying very costly, e.g. more than $100,000, $500,000, a few million of
dollars, (or if the family is unlucky) $24,000,000. After spending most
or all of the family money the patient dies like all poor people without
doctors and hospital. Staying at home in the last days may be more meaningful
and caring.
An expensive
doctor may ensure that huge sums of money is spent and the patient NEVER COMES
HOME ALIVE.
How Doctors Die
It’s Not Like the Rest of Us, But It Should Be by Dr Ken Murray.
Years ago,
Charlie, a highly respected orthopaedist 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% to 15%—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 not 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.
