How Doctors Die

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.

Great advice. My mom and dad are 79 & 77.
Dads health is failing him. It would be easier if he made his wishes known & got his house in order, however he still behaves as if he will live another 20 years.
He “blew” his money during the boom years and I think that hurts his pride making him want to hang on and work harder to prove himself.
Not to mention how bad it must feel for a strong man to hit the wall and retire to the rocking chair instead of going, going going.

I should have mentioned his health was great untill about 6 months ago and he never stopped. All day long, working 24/7 at one thing or another. He was not retired, self employed for since he retired fighter pilot since he was about 42.

He had open heart and has been back in hospitol with infection and lung problems. Now he is at home with shingles. We have not talked, however I can tell he is not happy at all.

Maybe God is calling home.

Thank you and winodog for your kind support.

I didn’t want to post that personal story, but it may illustrate to someone how prompt doctors can be in deciding to end a patient’s life.

She had been in a coma a little less than a week. I had three frustrated doctors with me in a meeting room wringing their hands, like they were more concerned about her quality of life than I was. One asked me how long would I need to make a decision on her breathing tube. He threw out the suggestion - “two days?”

I told him “I’m not buying a car.” They didn’t like my answer, and I didn’t like their suggestion.

...”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”...

You voice my own thoughts..This is an ad for the government to pick and choose life and death for everyone..Given full reign, (and I know saying this is a “No-no) it ends with a holocaust of some kind. How better to get rid of one’s political enemies than to cover it all up under “healthcare.” Many people choose not to go through heroic measures to sustain their lives if the situation seems hopeless. I do think some empathy should be in place when the very aged are in dire health conditions..In those cases, where only a short time is left, that time should not be spent suffering with tubes, etc., and having the person nearly comatose in the hospital, not able to communicate with family or friends. We have a situation in our family right now of a 92 year old who is in the care of his loving daughter, his wife and Hospice in his daughter’s home..They are with him as he takes his journey to eternity and he is at peace. This decision was made by the family, not a government death panel and that is how it should be. Most families will come to the decision that they do not want their loved one to suffer needlessly, regardless of the age.

My father also went to the funeral parlor he wanted to use, picked out his casket and paid for everything before he passed.....He died at 86 and had lived a long and fruitful life and was not afraid to die...He hated to be debilitated in any way...he was still living in an apartment and got a 2 bedroom apartment when I asked him why he wanted a 2 bedroom he said in case his health gets bad and he can hired someone to take care of him....he had all bases covered..Instead of a will, his money he got from selling the house on Mullet lake and the house in Detroit, he split amongst his 4 kids in individual savings accounts in each kids name but he kept the bank books until he passed. He had used a couple of different banks and all we had to do was take the savings books and close out the account...

For your fathers and my father generation the last thing they wanted was feel weak and useless. I say let him do as he wants even if he chooses to do something you think is silly at their ages...

But if there is a estate I would encourage him to make a will, revocable trust and Medical Power of Attorney...For that you need to find a good lawyer that works only in the area of estates and probate...just choose a time you think he will be open to the suggestion..

If he is not open to such a suggestion,you could explain that if he passed before his wife, she might have a hard time understanding and doing what would be required of her to do.......good luck and God Bless

My first wife was married to a doctor and she was a hospital photographer for several years so she has some insight. Doctors sometimes have a “god-complex” thinking themselves as heroes that must not make a mistake. They hold the power of life and death (they think) and must not lose one patient.
Sometimes they think that they know better than us little people what is best for us.

I think the important thing here is to take charge of your own health. Make our own decisions and not expecting “Dr. Oz” to fix everything (they can’t).

Modern medicine “treats” illnesses many times rather than “fixing” the issue. This is directly opposite of how we address “fixing the car”. What if you took your car to a mechanic and instead of fixing a burned out muffler he handed you a pair of earplugs? Doctors need to be honest and say “I can’t fix that”.

My mother had a heart attack in her ‘80’s, had 5 bypasses and then lived about 10 more years. After surgery I thought she never was quite “right”. Her last 2 or 3 years saw her mind degrade in a series of strokes. She didn’t recognize me the last time I saw her. Do I wish she didn’t have the bypasses? No! But it does give you something to think about.

(Is this article future propaganda hoping we will all die off instead of being a burden to the “state”?............um...maybe)

http://www.nrlc.org/euthanasia/willtolive/index.html

To prevent unnecessary surgery which will only keep you alive longer, but not help your condition, and to avoid being given too much pain killer with the intent to kill you, see the above link.

The “Torch” treatment story sounds like a no-brainer, pardon the unintentional pun. An agonizing treatment from which four months are expected, vs. a mild palliative from which eight months are expected then an easy death... what would anybody pick? I could see if the person wanted to offer himself to science or some such heroic deed, for the sake of trying to improve the miserable treatment through experimenting with variations until it eventually beat the palliative treatment or stumbled into a cure. But most who offer themselves to science do it posthumously, thank you very much.

Thank you, he has taken care of the will and trust. The other stuff amounts to very little and those seem to be the things that he holds on to so much like closing his business/hobby that runs in the red.

And your words ring true “I say let him do as he wants even if he chooses to do something you think is silly at their ages...”

I feel the same way and I preach that.

Based in my experience of 14 years of nursing, this is BS propoganda. I’ve known many nurses & physicians who have become I’ll & died over the years. All entered the healthcare industry as consumers just like any other patient.

This is a propaganda piece for the “duty-to-die” crowd that wants to convince the public not to consume expensive treatments.

My mom was practically dead in the hospital with a heart attack and was revived several times over the course of days by CPR. We will be spending our third Christmas with her since then. She lives a full life and you’d never know she has serious heart disease.

The author takes a few anecdotes and kernels of truth and turns them into a sweeping argument for denying and rationing even basic health care.

Sounds like his first priority should be tort reform.

I’m not so sure. My FIL had advanced directives...no feeding tube, no ventilator. He contracted MRSA pneumonia after a surgery to repair his hip (he had fallen.) He was 93 years old, we had his wishes in writing along with a health care surrogacy document and almost everyday the physicians pushed for a feeding tube and ventilator. He had been transferred to a “specialty hospital” for folks with chronic problems (I believe you could substitue the word “terminal” conditions.) He was the only patient in the hospital that was not on a ventilator and did not have a feeding tube. One woman, whose husband was in the room across the hall, told us how she had been pressured into the ventilator and feeding tube after her husband suffered a massive stroke. And now, many months later, he was still in the same state, physicaly with no improvement and no response, but alive because of the machines.

Years ago I attended a seminar with Dr. Koop and Francis Schaeffer. I can distinctly remember Dr. Koop commenting on the advances in modern medicine and not starting extraordinary measures when someone is deemed terminal(I believe the discussion centered around Karen Ann Quinlan.)

Gee. Did anyone ELSE click on the link and go to the site that hosts the article?

Let's see...first off, Jerseyanexile, how about keeping the article title as it actually reads? I can see you haven't been around Free Republic all that long, but people frown on editing the title of articles. You should have it changed to reflect the actual one at the website: "How Doctors Die It’s Not Like the Rest of Us, But It Should Be".

And the other articles at the site: "Who Needs Doctors, Anyway?" and "Will The Healthcare War Ever End?" which contains this revealing question: "How did an almost universally acknowledged good like healthcare become a source of such titanic strife? "

I am sure it was a slip, and what the author REALLY meant to say was "acknowledged good like UNIVERSAL FREE PUBLIC healthcare".

And just look at the sponsors of this website, "Zocalo":

Well, that is a Murderer's Row" of liberalism if there ever was one. If you don't believe me, and hey, why take my word?) just Google a few like "New America Foundation" and why even bother to Google "Department of Cultural Affairs, Los Angeles"...Gee, ya think there might be some federal grant dollars given to the Department of Cultural Affairs, Los Angeles which are turned right around and given to this "Zocalo" website?

Jerseyanexile, here is some advice: If you want to peddle Obamacare, Free Republic is not the place to do it.

BINGO!

All of my estate planning clients execute the NRLC “Will to Live”.

I include it at no cost.

I just guest lectured for a college medical ethics class about end of life issues and the Will to Live and rationing under Obamacare were topics I addressed.

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