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How Doctors Die
Hugh Pickens writes "Dr. Ken Murray, a Clinical Assistant Professor of Family Medicine at USC, writes that doctors don't die like the rest of us. What's unusual about doctors is not how much treatment they get when faced with death themselves, 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 because 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. 'Almost all medical professionals have seen what we call "futile care" being performed on people,' writes Murray. '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."' 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. 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."
It's traditional to see life as a sacred thing that must be preserved at all costs--to a point. There was a balance. This has been true throughout human history, with the exception that in the past couple hundred years we seem to have collectively forgotten that in order for life to go on something else has to precede it in death. In an era of ever-increasing lifespans, global populations and expectations of one's quality of life, we are engaged in a losing game against the power of exponential arithmetic.
When it's time to go, it's time to go.
and not screaming in terror like the passengers in his car.
But all kidding aside, I agree that the so called "futile care" exists for the patients loved ones and not the patient themselves.
"Have you ever thought about just turning off the TV, sitting down with your kids, and hitting them?"
...almost completely. There is a point, and we can certainly debate just where that point is, beyond which we are no longer "healing" and are merely prolonging the suffering of our patients. The common layman's expectation is that anything that could be done, should be done, regardless of the likely outcome. Pointing out that Grandma's time has come, so to speak, and that the "right" thing to do is to make her passing as comfortable as possible, is something that western medicine does not do, generally. That needs to change.
a patient suffers from severe illness, old age, or a terminal disease
Had one branch of the family that was real religious. Didn't believe in anything even *resembling* euthanasia. Insisted on keeping my aunt alive, no matter what. It was an ugly, sad end. Bad stuff.
Had another branch that had a much better attitude, IMHO. Had hospice care that was not afraid to push the painkillers well into the dangerous zone, a "do not resuscitate" understanding with the hospital, etc. My cousin's mother died a *much* more noble death.
Can't stop death from coming. And there is a time to fight for life, but also a time to recognize when the fight is over.
SJW: Someone who has run out of real oppression, and has to fake it.
You really should read the article. It isn't bitter at all, and is some serious food for thought. If you've not had a close individual diagnosed with a terminal disease and this isn't applicable, then you're a very lucky person. If you have, the article raises some interesting arguments for how you or your loved ones should approach such news.
It has been two weeks since my father passed away from lung cancer, so I am more sensitive to the topic than normal, but the idea that we should more carefully evaluate how we want to live our remaining days/weeks/months when faced with aggressive, difficult treatment, is one worth thinking about.
It's a little maudlin - it's hard not to be with this topic - but it does bring up something that most people explicitly don't want to deal with. He points out that the people who do explicitly deal with death and dying tend to do things quite differently than 'normal' people. It isn't a scientific discussion, it's a personal, anecdotal essay.
You're perfectly welcome to muddle through life - it is exactly what we all do. But I thought it was a reasonable essay and one that's been covered many times in the past. It is clearly written as a counterpoint to the "do everything, medicine will solve all our problems" view that is quite prevalent in this world. The big problem is it is damned hard to tell people what to expect especially when they are faced with a fatal illness. It's hard to tell someone how hard chemotherapy would be for that individual. It's hard to know how to balance a few months or years of 'additional' living with the downsides of frequent hospitalizations, invasive procedures, dangerous drugs and additional pain.
At least in the US, overtreatment is a huge issue. Anyone but a trained biostatistician is really not in a position to intellectually tease out how effective treatments for most diseases really are (or in reality, how ineffective). So, when you are unable / unwilling to think a problem through, you emote it. Then it gets complicated.
Faster! Faster! Faster would be better!
Of a neurologist who had a stroke, and wrote an article about it later. It was really amusing how she wrote about it. She knew what was going on, she knew the signs, hell, she was an expert. She called for help of course, but, she talked about how during it, she was having a rich internal dialog about the process... thinking of what functions were broken, how it was manifesting and how she experienced it....
I think that is a lot of it. Other studies have found that the groups who spend the most on healthcare at the end, and spend the most time in hospital beds prolonging life are... the religious people. Atheists are much more in line with doctors. Why?
My own hypothesis, which fits my own experiences to is... that belief in an afterlife, in the absence of other experiences (like working in healthcare and seeing people die all the time), lets people ignore death. It happens later, there is life afterwards, everlasting life.
Atheists and people who deal with death on a regular basis have no such excuse. As an atheist, I came to terms with the lack of an afterlife early. I remember being maybe 14 years old when I realized that I was going to die, that was going to be it....and even that.... I didn't want to spend my time in a hospital bed. I knew...then...at 14, that when the time came, I would want to just die, even if it meant taking my own life. Not a desire to kill myself now or anything depressing like that, but an affirmation that life will someday not be fine, and never be fine again, and that when that happens, I know I can check out.
I have talked with some people who struggled with suicidal thoughts, serious ones, not attention whores. A few said that when they decided how they wanted to die, and put together a cyanide pill or some such.... just knowing it was there was enough. Knowing that they could end it provided a sort of final resolution, a comfort that allowed them to move past it and stop thinking about it.
On the other hand, I feel bad for the very religious. Doubt is common, almost inevitable. How can you not be on your death bed and wondering if those stories were true? For a religious person to be wrong, could mean so many things, hell, a different religions hell.... what if you chose the wrong god? For me as an atheist, whats to doubt? If there is an afterlife, great....but a heaven one seems just as unlikely as a hell. We literally have nothing to worry about.
"I opened my eyes, and everything went dark again"
IT has something similar. Everyone of us has experienced it.
Poor bastard brings in a laptop with that forlorn look on their faces. "Dude... save my porn". You boot up and the drive is not recognized. Take it out, hook it up it for diagnostics and it is dead. No S.M.A.R.T status, nothing. You gently touch the drive and there are no RPMs .
You sit him down, and explain carefully, that the drive is dead. It could have been overheating from leaving the laptop on the bed while going to town with that whole bottle of hand lotion.
There is an outside chance, experimental even, that you could open the drive and transplant it into a working one. The transplant waiting list is not just long, but extremely expensive and not guaranteed. (I had one guy explain to me that the platters looked like an airplane came in for a hard landing and scratched the whole surface deeply).
He leaves laptop in hand, tears freely flowing, and you look to your buddy and tell him, "Dude if I ever lose my porn like that just kill me". Then you remember that you have knowledge and it is protected with ZFS and scrubbing. Thank God.
I am a physician.
I only take my children to another physician when I honestly think something is wrong with them. I argue with my wife constantly over it (I am not a pediatrician), as she wants them on antibiotics when they get the cold, etc. She wants to take them to a "real doctor". (FYI, I'm a cardiologist.)
My son has some medical issues and needs close care, but I stay out of the way of his team, and most of them (possibly all of them) don't even know I'm in the health care field.
I think you'll find my attitude towards my children's care to be fairly representative for my profession. Certainly it mirrors what I see in my colleagues and physician friends.
Well, I'm not entirely sure on that one. First, there are disputes over how to even perform CPR for maximum effectiveness, with some saying that chest compression alone produces better outcomes than a mix of chest and breathing. If the doctors aren't in agreement over what CPR should be done, and different methods are being rolled into a single line item, then the statistics for the outcome really don't mean anything useful. It tells you that *something* is ineffective, but it cannot tell you what that something is.
Second, all doctors either swear to the Hippocratic Oath or implicitly sign up to it by becoming doctors. Since the Oath is witnessed by an independent third party, it is arguably a legally-binding common law "gentleman's agreement"/"verbal contract". Technically, the Oath states that doctors should do no harm and minimizing suffering is technically doing just that. However, very few Western nations interpret things that way. If they did, assisted suicide under well-defined conditions* would be legal. It isn't because they don't. As such, doctors end up in a double bind. Do they do the clinical least harm or the legal least harm? Whichever one they do, they violate the other.
*I am not a fan of assisted suicide, but the only way to bring the ethics and law together is to have some cases where it is legal. IMHO, the Oath should move from common law to contract law and be the defining standard. It's a "floating" standard, since different levels of technology and understanding will alter what least harm is actually achievable, and it is a far more credible benchmark than the religious and political whims of the day.
It's a small world and it smells funny; I'd buy another if it wasn't for the money; Take back what I paid (SoM)
Troll?
I'm a physician that works for a hospital.
I have the futility talk with patients and their families quite frequently. It kills a little bit of me when I hear a family say they want everything done. And a little more dies every time I run a "mega code", lasting over an hour trying to save someone who if by some miracle they survive, will have no quality of life and be dependent on machines for breathing and feeding and urinating (hemodialysis) for the rest of their life.
"Where there's life, there's hope" is a common saying in the community I work in. Every time I hear that, I cry a little inside.
I have never had a hospital administrator even hint at anything that would extend suffering. If anything, the administrators like us to call the local hospice services, to free up beds for individuals who will survive.
Help! I'm a slashdot refugee.
What morons rated this '5 insightful'? Ken Murry is not bitter and angry, he is thoughtful and kind. PCM2 has done the typical thing of morons: he assumes his imagination = reality. Give us all a break and don't post if you don't even read the article.
This is so wrong. The majority of those providing care to the terminally ill know it is pointless and don't want to do it, even for the money. Their hand is forced by legal requirements and family members.There are plenty of other things to be done that will make a difference, but they get pushed to the back because they aren't considered "life-saving".
Often the effort to extend the terminally ills life another day/week/month is written off and not paid back in full. The profit margin at that point of life is very slim. Even procedures that aren't lifesaving and are becoming more routine have slim margins. For example, there is no (ie, zip, zero, nadda) profit on total knee or hip replacements at the hospital where I work. We have to do them because of legal requirements, but insurance won't pay more than a certain amount.
Profit could be maximized much better if the vast quantities of manpower and resources dedicated to saving those already dead were instead allocated to those who will live to pay.
As a healthcare worker, it pisses me off to see people ranting about the costs/quality of the US healthcare system without knowing anything about it other than their own pocketbook.
A bit more than 30 years ago my mother was diagnosed "terminal" cancer. To the point where she was told to go home and die, less than 6 months to live. Instead she signed up for at the time totally experimental neutron radiation therapy (specifically her doctor lied to get her into the program, and when she got to the university running the experiment she was told "if we had known your condition we wouldn't have accepted you")...
Her life was shit for years because of that treatment.
So here we are, 30 years later, and she's still alive. The shit she went through is mostly forgotten, the health issues she lived with from the radiation therapy have mostly been replaced by more typical "60+ year old American" health issues. She has has now spent half her life as a cancer survivor, and while it hasn't been chocolate and unicorns she seems happy to be alive.
That sort of colors my view, I'll admit, but it seems to be a point that gets lost in a lot of this discussion.
1) Not all doctors take the Hippocratic oath. I am a doctor, and while I appreciate the sentiment behind the oath, I did not swear it myself.
2) There a many different forms of the "oath". Nobody today takes the oldest know form, which of course is likely not the "original" (it is unknown if Hippocrates actually was involved in the original oath anyway). Did you know that the original oath prevents a physician from performing urological sugery, abortions, or assisted suicides? And did you know the original oath required the oath-takers to give free medical care and support to their teachers for life?
3) Medical ethics has moved way, way beyond this simplistic and confusing Oath as the end-all-be-all. Re-adopting it would be like swapping out the laws of England with sharia law, or even the ten commandments.
Bringing up "the oath" is entirely irrelevant to the discussion and is a red herring. It would also be a big step backwards to include it in physician training in the future, except as a historical curiosity.
Why wait until you're faced with aggressive, difficult treatment? How do you want to live your remaining days now? Your life is already terminal enough to carefully evaluate that.
How about one of the author's nurses turning him over to the police for obeying a patient's desires to not be put back on life support? You think that doesn't support his notion that doctors suggest treatment plans with the specter of a police investigation in the back of their mind?
How about him keeping his cousin in his home after his cousin was found to be terminally ill? You think there isn't a difference in the cost of the bottle of pills they sent him home from the hospital with as opposed to forcing him to stay alive?
Have you seen what chemotherapy does to people?
Do you know the monetary and emotional cost of forcing a piece of meat to keep on breathing long after it's expired?
There's plenty of food for thought in this article, and you think geocentrism has something to do with it.
What the hell is wrong with you.
Your uncle needed someone with medical power of attorney to be there with him. It sounds like, had he chosen to arrange that with you, you could have helped him suffer less. I say this with the hope that anyone else reading this could arrange things now, before their elderly relatives aren't capable of signing such legal documents.
My wife had medical POA with her 94-year-old grandfather when he got sick and died in 2010. She literally had to sit by his bed to be there when a random doctor would come in and try to intubate or give him something the legal paperwork he'd signed years ago said he would refuse, and she had to tell the doctor NO and wave the POA and No Heroic Measures paperwork at him. She had to do the same thing when the social workers would come by to try to plan his treatment. each new care provider would make or take a photocopy of all the paperwork. (My wife had like 40 copies made.) This took a few weeks until eventually he was transferred to hospice. Even there one of the regular care nurses was furious when they stopped all treatment. In this case, though, the hospice nurse told the regular nurse to STFU and stay out of the way while my wife watched her grandfather die.
With a medical POA and No Heroic Measures paperwork, not only would the paper exist but there would be a family member there with the legal authority to enforce it.
It doesn't hurt to be nice.
"it takes more and more coffee just to reach normal alertness"
that would explain why my 95 year old grandfather who has been drinking coffee for 84 years, now drinks seven thousand five hundred and twenty one gallons of coffee each morning.
He started with one cup, one fine morning in 1927. And from there it just took "more and more coffee just to reach normal alertness".
Without it, it's like he's preserved in carbonite.
Thank you for your helpful explanation of the dangers of coffee.
How about one of the author's nurses turning him over to the police for obeying a patient's desires to not be put back on life support?
Actually, that isn't what he claimed. Even with just his side of the story, we know it wasn't that; a nurse fulfilled her mandatory reporting requirements because the paperwork wasn't there with him, as it normally would be. The system worked, the paperwork was checked and his wishes had been followed.
Actually it seems to be a picture of the system working, regardless of the doctor's view.
10 years ago, at the age of only 43, my Ex-wife was diagnosed with an advanced Stage IV Melanoma. The normal size for the primary tumor to be classed as stage IV at that time was 8 mm to 12 mm, and hers was about 20mm on discovery. The assumption is that a Melanoma that large has to have metastasized unless absolutely proven otherwise. The location was on top of her scalp, making it very likely by the standard model to have drained tumor cells into her lymph nodes just because of that location. The original physician diagnosing her gave her 3 to 6 WEEKS to live and was incredibly blunt about it. She is, however still alive, thank God. (And no, I didn't pull a Gingrich, she divorced me about 4 years later, then we found out the relationship could be saved, put it back together, and just never bothered to do another ceremony. We have great fun making my staid, conservative daughter roll her eyes at us.).
I don't like to tell people who are terminal about this. She beat odds that were quoted in the standard books on cancer as 10 Billion to 1 or worse, repeatedly. I'm not by any means totally convinced that it was a miracle, but her surgeon swears something guided him, literally forcing him to cut a small extra flap extending for about 2 inches along a scalp vein before it would let him put the scalpel down.
An experimental treatment program at Duke University got mixed results on a bunch of other people, triggered the weirdest side effects anyone ever saw in her (She was speaking with a foreign accent a few days after some sessions, spoke some fragments in recognizable languages and some that may have been a really exotic tongue or just some noises (and all she speaks normally is English and 1 year of Spanish, but there were times her German was excellent, and one where I recognized some Italian, but then, my own Italian is not that good), she had occasional weeks with feeling fantastic, not sleeping at all, and working like a fresh, new meth addict, while running a 103 fever and losing 10-15 lbs. a week, then other weeks with no other physical symptoms except where she slept for 33 to 48 hours at a time, and the program may or may not have been a factor in her survival - it's been dropped as inconclusive). She had other symptoms that would fit schizophrenia, things such as putting the car keys in the refrigerator's butter dish 'so they wouldn't melt'. None of those periods lasted more than a week or so before it was something else.
I've got no explanation for why any conceivable God would do such a thing as a miracle just for her, or wouldn't for so many other people, or why a miracle would be so strange. Worshiping some form of God for doing this almost seems irrelevant.
I know I prayed. I mean waking up at 2 am next to her with sweat pouring off of me and telling God how sure I was that there were things she was still needed for. I don't remember doing a lot of praying about how I would make this or that bargain with God if he would only change things, but as I understand it, a lot of people do pass through a stage where they offer bargain after bargain if God or reality or whatever will just fix the bad thing. I also felt a lot of anger at times, as did she. Whether you feel it and whether you express any of it to the dieing person, please understand, you are not there to vent. If admitting to your own fear or anger helps the patient tell you about theirs, then you do it - if it seems to make them even a bit uncomfortable, you don't.
Right now, I'm wondering what to say to her all over. Her older brother was just killed by a criminal on Christmas eve, Shot right after he opened a safe. The murderer had been out of prison for about 24 hours. She's basically in the shock stage right now, but she's seizing on some things in the news and starting to ask some very angry questions about how the authorities let this guy loose. So now I'm wondering what to do, not just for now, but every time the holiday season rolls around.
Who is John Cabal?
You mean this one:
Taken absolutely literally, it only forbids one kind of abortion. I would interpret this, in light of "I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous" to mean avoiding any kind of abortion that is likely to be destructive to the patient, but that any kind that is likely to be helpful to be entirely legitimate. The requirement of being for the benefit of the patient is, IMHO, the ruling clause and all others are contextual interpretations of it.
Urological surgery, the Oath states, should be performed by a specialist. I don't see any technical problems with this -- I wouldn't want a GP to be performing it either. Surgery is best left to surgeons, as the Oath says. ("will leave this to be done by men who are practitioners of this work"). General Practitioners are not brain surgeons, heart surgeons, urologists, etc, and should indeed refer the patient to a specialist. (I don't consider surgeons to be doctors in the sense meant by the Oath. The Oath seems to make it clear that it is intended for village doctors making house-calls, or GPs in local practice, with similar but suitably-adjusted Oaths being required of those trained in highly specialized areas of medicine.)
Frankly, the Laws of England would be better served if attempts to revise or delete elements of Common Law were examined in light of the original intents of such law, and if both the Houses of Parliament and the practicing lawyers were familiar with the purpose of Alfred's Book of Dooms, the elimination of Sovereign Immunity in the Great Charter, and the reasoning behind the English Bill of Rights. Sure, nobody would want to revert to Saxon law, but the reasons for why it was what it was have changed surprisingly little. It was a careful balance of revenge, punishment and mercy, a balance a lot of modern laws don't have. We've progressed a lot in theory and can strike a much wiser balance today, but unless you start from the
It's a small world and it smells funny; I'd buy another if it wasn't for the money; Take back what I paid (SoM)