Late last year, Zócalo, an online public square that encourages the exchange of ideas, published an essay called “How Doctors Die,” by Dr. Ken Murray, a professor of medicine at the University of Southern California.
Personal, heartfelt and utterly illuminating, the essay describes how our culture extends the lives of the elderly and the terminal by taking extreme measures often beyond what patients desire or families understand. The essay contrasts those common practices with what doctors themselves generally choose for their end-of-life experience.
Our post last week addressed many of the issues, medical and psychological, any thinking human faces when it comes to end-of-life care.
Murray’s tale, as told from the medical professional perspective, has been selected for inclusion in a collection called “The Best American Essays 2012” to be published by Houghton Mifflin. No one should pass judgment on the end-of-life decisions someone else makes, as long as they’re informed. But doctors deal in death, and you might be able to understand how they’re less able to withhold judgment, even if you don’t agree.
The following excerpts artfully show the divide in the hope that patients can see alternatives to the default medical practices that many might wish to forgo. And to understand why someone else might make a different choice. To read the whole essay, link here.
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.
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. … 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.’ … 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 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.
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. … 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.
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.
Our patient safety newsletter offers advice about legal measures you should take in advance of medical need. To learn more about palliative and hospice care, visit the website of the National Hospice and Palliative Care Organization.
Hospice care usually is provided in the patient’s home, and sometimes in freestanding hospice centers, hospitals, nursing homes and other long-term care facilities. It focuses on comfort in one’s final weeks, not cure, and is covered under Medicare, Medicaid, most private insurance plans, HMOs and other managed care organizations.
Palliative care embraces the principles of hospice care for patients earlier in their illness or disease process. It might involve therapy, depending on the individual’s needs. Palliative care, generally, evolves into hospice care as the illness progresses.