Tuesday, February 19, 2013

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.
Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC. This post was originally published at Zócalo Public Square, a non-profit ideas exchange that blends live events and humanities journalism.

  1. ICUNurse2 says:
    As a icu nurse for the past 20 years i have observed several things. 1. the doctors are rarely upfront about long term outcomes for terminal illness. 2. The patents wishes are overturned daily to prevent “the family from suing”. 3. If the doctors were actually upfront about what the patient can expect and how futile some treatments are, the families get angry, and refuse to listen. and last to prevent all of this, EVERYONE should make their wishes know to their family, and the md. It should be discussed in no uncertain terms what you want, long before the question of what you want is needed. And your wishes should be followed.
    • kelli says:
      I am a RN of 30 years that right now is sitting with my mom in her home while she is under hospice care. She will die today of that I am sure because she is unresponsive, no urine output for 24 hours, febrile and not swallowing. It is awful to watch your own mom die but it has been worse watching her repeated hospitalizations that never added to her quality of life. She has lived with heart failure for too long and her poor, tired heart is done. I am just keeping her comfortable with morphine right now. I have already discussed with my children my wishes since I do not want to prolong a life that has no quality to it. I think the doctor in this article is on the right track. Live out what you have left with quality rather than being a prisoner of your home, oxygen, meds, pain, breathlessness, and depression. As a nurse I have seen it too often. Not saying there is no such thing as hope, but there is also facing reality. My mom’s doctor was always honest with her so she was aware of the terminal aspect of her life but 911 was always called on her when she crashed to try to prolong her life. I do not want to live my life like this and can see the doctors viewpoint. Everyone has to do what they feel comfortable with but the unbelievable amount of money spent on prolonging life when it will make no difference is bleeding insurance. Patient education has to be more universal to allow for better choices to be made that are more realistic. For now, I am praying for my mom to have a peaceful quick death and be free of the suffering. I will miss her greatly ,but not watching her suffer and deteriorate as she did, being beaten down and defeated by a disease with no cure and no future.
      • Danielle says:
        I lost both of my grandparents to lung cancer (my grandma also had congestive heart failure) in the last 4 years. Both chose hospice care. I’m grateful for the help and support hospice gave my grandparents, and the help and support they gave me as a caregiver.
        I’m sorry you are losing your mom. May she rest in peace. And I wish you peace and comfort at this time.
        At least we can say they did it their way, right?
      • karen says:
        I wish for a peaceful end to your mothers life. I just lost my mom after agreeing with her that she should have surgery to repair her aortic valve. She did not survive. She died peacefully, but I hate that we put her thru that. May your mothers memory be for a blessing!
      • Kelly says:
        very sorry for your loss, I also sat with my mom while she passed from cancer she slipped into a coma and and passed 2 days later…
      • Lori says:
        I am an RN as well and watched my mother die from leukemia. She was 80 and decided against chemo, anything radical treatment. It was the hardest thing for me to do was watch this vital woman slowly sip away from me. Wither away to nothing…but slipped off peacefully one day to join my beloved Daddy in Heaven. A man she has been without for 30 yrs…she was ready to go.
    • Beth says:
      This has nothing to do with how doctors die. I agree with the above comment. . Even though this man prolonged survival rates to 15% as a physician, that 5-15% to get to five years doesn’t describe the course for metastatic cancer (stomach lump and it’s pancreatic). Fifteen percent with what treatment they will be undergoing is a catch 22. If it was quality time, so be it. This also got my attention; why does an orthopedist work on something for pancreatic cancer? Weird. My guess is he knew it was his time and chose wisely. Just as some of us other cancer patients do. Doctors DO die like the rest of us! This article is about patient, physician or average joe citizen, end of life care.
      • David says:
        It wasn’t the orthopedist that worked on pancreatic cancer, it was the doctor that did his exploratory surgery.
        I think you missed the point of the article, but it sounds like you agree with it anyway.
      • Laura says:
        The orthopedist was the one who got the exploratory surgery and was diagnosed with pancreatic cancer, not the one who performed the surgery.
    • doc says:
      Fact of the matter is nurses don’t have these conversations with patients/families. So it makes no difference to me if you are a nurse in ICU for 20 years because when you make blunt statements like “doctors are rarely upfront about long term outcomes for terminal illness”, . In fact in my experience, most doctors are upfront about long term consequences of terminal illness to avoid getting sued. All in all, it is not about getting sued, we are ethically taught to cater to patients wishes. Transparency has been shown to cause less lawsuits and most doctors are aware of this.
      Secondly, the patients wishes are not overturned to avoid getting sued. Thats a very superficial statement for someone who has 20 years of ICU experience. Their wishes are usually clearly stated in the chart. If it is not stated in the chart, then all efforts are made to understand what the patient’s wishes might have been from the family members so that the wishes of the patient can be honoured and respected. Clearly, as a nurse you do not partake in these discussions with patient and family and to make such statements is absurd by blaming doctors.
      • orly says:
        Rebuttals tend to be more effective when they’re not made personal and hurtful, it doesn’t make your point stronger it just makes you look like a jerk. Blanket statements really don’t work on this topic, because of the human element in the equation. Different things can can happen for the same situation depending on location and care givers.
      • RN says:
        Many doctors do have this crucial conversation but aren’t at the bedside after the patient or family member has had time to process the information and have questions. As a nurse I have had these conversations with patients and families many times. Having said that there are physicians who will not discuss the consequences of terminal illness with patients or their family members. Whether it is because they feel like a failure if they “let” the patient die or they really feel like they can improve the patients quality of life, I’m not sure. I do know that every patient deserves to have this conver
      • Jake says:
        You are obviously a very defensive doctor. The nurse was was not blaming you. She was just explaining very casually, that patients family are usually the ones who inflict that kind of suffering due to their stress. The “not getting sued” is just a blunt synonym for “ethical”, because she was writing her comment while feeling slightly agitated at the current state of affairs. You don’t have to be too worked up.
        Secondly, your counter attack on nurses on “Fact of the matter…” makes you totally unprofessional and disrepectful. All just because you want to defend yourself. I would expect doctors to control their emotions better.
        I think as a doctor, you should work on listening, understanding and comprehending others. It will help make you a better doctor.
        • Stef says:
          Good statement Jake! Very true! Doc- I have a lot of respect for physicians- and being the one to actually tell families their options must be really difficult. As RN’s we do not have that role- but “RN” is right… we are the ones who spend 13 hours day with these families. They trust nurses because we are forced to establish relationships with them. We do have a lot of conversations with them regarding end of life and understand their true wishes. It has been bc of nurses urging physicians to have honest conversations with families that many of my patients have been able to die with less suffering and more peace.
  2. Beth says:
    Thank you very much for this wonderful article… It addressed issues that I have tried so hard to communicate to my family… I am a Respiratory Therapist… I know not the usual title of Dr or RN or anything like that but what people don’t realize is that respiratory is the one that’s there in traumas, ICU, we are the ones breaking those ribs during CPR, we are the ones managing the ETT to secure that airway, we are the ones managing the ventilator that is keeping that person alive…. We are the ones that they call to turn the machine off to let someone go, we are the ones that transport to do that brain flow study or the futile MRI’s that aren’t going to tell you anything different than the one the day before… It us so hard as a professional in the field and that close to the end of life aspect or where the emergency decisions are made to try and explain to someone that hasn’t seen what you’ve seen or taken care of what you’ve taken care of to understand what you are saying when you try to discuss your own end of life care or the what ifs care…. Even after careful explanation, unless you’ve been a healthcare provider of any sort… It’s hard for the rest of your family to understand or except the decisions your trying to put forth… What bothers me the most I guess is that even though I have made my wishes known… Even though they are documented… That they can still be overridden… That the next of kin or medical power of attorney can change it… And what breaks my heart is that I know if I were in a car accident tomorrow and brought to the hospital they would say “do everything” without stopping and looking at the outcome… If I’m not going to be ME or have any kind of quality of life than just let me go…. And if I did come down with some kind of terminal illness. I wouldn’t want to be spending my last months or money that I could leave to my family on futile care… Comfort care, yes I would want to not live my last days in pain but to prolong it just feels inhumane… I sit with some if my patients… Just holding their hand sometimes and pray for them to pass so that they would not ne hurting anymore… I’m soo soo sorry for the rambling comment… I never comment on anything… But this pulled a heart string that I feel deeply about… Thank you So much for a wonderful article!!
  3. Christa says:
    I’m not in the medical field at all, but I totally agree with this article. I didn’t tell my dad, but when my mom had a massive stroke, I prayed for her to pass quickly, because I knew that if she didn’t, he would want to do “everything”, in the hope that she might wake up, but she had suffered so much brain damage that that really wasn’t a possibility. Even so, he would have spent his last dime, and never left her bedside, hoping. I don’t want that to happen to me. I don’t want them to declare me dead prematurely, in order to harvest my organs, (I have a donor dot on my license), but if “I” am gone, let me go. I’d rather die on my farm, and have my ashes scattered here, than suffer in a hospital for an indefinite time.
  4. Paulo Ramacciotti says:
    Congratulations for the nice words… I live in Brazil, and as a physician it is great to read an article like this, that gathers all my beliefs and experience about this special and time of life, and that surelly should be treated in a more respectfull way than it is: our deaths…
  5. Judy says:
    I have spoken to my doctor and have a medical directive regarding extended care. I have also spoken to my family. Quality is so much better than quantity. I know where I’m going after this life is complete. I look forward to seeing my family again. Thank you for this article. I agree with it completely.
    • Kim says:
      My husband and I both also have directives that say specifically we don’t want to be put on life support, etc, should something happen to one of us, But I also think its because we also know, like you, we will see our families again, and know where we will be going in the next life. What a comfort that brings to us and our families! This was a great article!
  6. Liz says:
    As a nurse, I like to think I will go as Charlie and Torch. After 40 years of watching people decide their options I’ve learned that none of us really know what we will do until it happens to us; whether we are medical people or lay people. Doctors are healers by nature but even in cases of poor prognosises, families don’t understand and need time to adjust so for that reason it’s not always that the doctor wasn’t upfront about poor outcomes, but families can’t always hear the truth.
  7. As a person who has suffered with pain and health issues for 55 of my 60 years, and given my ETA fro death do to COPD and other factors, I am sad to know No one will be there for me to stop the medical professions abuse of my mind, body and emotions. I have seen my mother suffer before death, and my father. No Code Is not enough to keep from needless suffering. It is time to treat humans with as much compassion as we treat our “pets’ I know the US is no super power…but saddens me we are still in medival times.
  8. Martin Cosentino says:
    Dr. Murray, such a heartwarming and kind approach to the steel edge of today’s medicine. My father-in-law, a retired chief surgeon at a large Cleveland hospital, suffered a stroke and was hospitalized for two weeks. He had discussed these medical matters with his wife many years previous, and she was aware of the DNR requests he had made of her. About 5 weeks after the stroke, he suffered a cerebral hemorrhage and went into a coma. There was no saying of goodbyes for his children, and the doctors explained why. His wife gave her consent to turn off the switches.
    We have been seduced and charmed by the machines and the technology, and the trust and confidence we once had in the doctors’ judgments and skills has given way to a ‘plug them in and everything is allright’ placebo that only painfully delays the inevitable. I can only hope that thousands of doctors metaphorically ‘disconnect’ themselves from the mechanical medicine factories we run in the US today. That the illusion of machines and sometimes hundreds of thousands of dollars does nothing to deter the end-of life we all must face, is a lesson in stoicism we desperately need. It speaks of a strength that not only aids us in the everyday living we move through, but the final endurance we will need, not only for our loved ones, but ultimately for our very own selves.
  9. Burt Goldberg says:
    It happens to researcher in Medicine as well. I am Professor of Biochemistry and Research Professor of Molecular and Biochemical Parasitology. Went las year for a friend to given me my flu shot. He realized i was very sick and anemic. Next thing I know I have a diagnosis of Myleofibrosis and having a 7.5lb spleen removed and a bone marrow transplant. I am very luck and have had exceptional care (MSKCC) by my doctors and especially the angels on Earth, my nurses and N.P’s. With out their care and allot of luck, would not have just celebrated the new year and returned to my department and lab today! By the way how do you say thank you to tow enormously special people, a friend who cared and got a rare diagnosis right, and a person so generious that she donated her bone marrow so i am alive today.
  10. Annmarie RN says:
    Amen! This article should be posted in every waiting room in every hospital for families to read. Knowledge is a very powerful tool!
  11. Jan says:
    A very enlightening and honest article. But, I am upset about one thing–the nurse who reported the MD for “pulling the plug”. That nurse should be disciplined and have her/his license put on probation. I have been an RN and CRNA (nurse anesthetist) for many years and know that the fear of pain and loss of dignity are prominent in the minds of those who are dying or have debilitating chronic diseases. It is the nurse’s job to comfort the patient and to be responsive to the patient’s requests. No one has the right or the qualifications to play god.
  12. Victoria says:
    I have been a hospice nurse for the last 4 years. My first hospice patient was an 82 year old doctor who was dying of renal failure and prostate cancer. During the admission process his wife told us that when he realized he was no longer treatable, he gathered all of his family together and told them he was dying. He told them he would grow weaker, sleep more, eat less, and occasionally be confused. Then he would likely slip into an unconscious or semi-conscious state and die. He told them not to be sad, because this was the kind of death he had prayed for every day. He told them that he wanted them to make sure he died in his bed, with his dog, and because he had this discussion with them, that is exactly what he did. I had worked in infant critical care for 13 years prior to that and had experienced every kind of horrible, drawn out, painful, undignified kind of death that could be inflicted on a baby in the attempt to save them. This man’s serene death had a profound effect on me. We have somehow forgotten that living longer is not always the appropriate goal.
  13. Imegahan says:
    We the public are misinformed. We go about our daily lives, hearing snatches on medical miracles, and so formulate an unarticulated belief that should the need arise we will ask the fairy god doctor to wave a scapel (or laser, or such), grant our wish (for extended life), assuming this means something like what we’ve always known.
    Farrah Fawcett was lovely, brainy, and brave. She did more for availing the public to the real side of sickness, decline, and death, than I ever knew was possible. So often we glorify the process of fighting to the last breath, like it’s all akin to Chariots of Fire, or Rocky, or some other David and Goliath story. We put on the boxing shorts and gloves, because we do not know how to die (let go). We need to become informed now, when there is no crises, and we have our senses; and we need to make an educated informed choice. Thank you.
  14. Pat. S. says:
    My father-in-law, at 80+ yrs, had a dire heart condition. They found colon cancer, which they thought might have already spread. They chose to take out the colon cancer, assuring the family that even with his bad heart, the surgery had a 99% chance of success. Success of what, I wonder. He lived a few weeks in agony after the surgery, bound with all sorts of tubes stuck everywhere, with a cocktail of drugs to keep his heart going, but not enough to heal the surgery, which ruptured. He was too ill for the drs to go in and repair it, and was in awful pain, the treatment for which interfered with his heart meds, so had to be used sparingly. I feel the doctors were just “playing doctor” with this patient, and it is criminal. Pop had to wait until my brother-in-law could bear to let him go, which I don’t criticize. But I do take the lesson, and will NOT let this happen to me or anyone I love.
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  16. cass says:
    I work as a respiratory therapist in an urban Detroit hospital. It should be the patients personal physician that generally should speak to the patient. Thats a moot point for most of my patients as they use the hospital for primary care. I get so upset when end stage disease pts and family are asked do you want everything’ done. No one explains that “everything” means a teach and peg tube then off to a nursing home for a miserable death. Believe me their ARE worse things than dying. Wish we had. national definition for DNR status. Where I work you must be a DNI and DNR to allow comfort care. I think approaching a patient with the term comfort care would be so much better than do everything…
  17. Ruth says:
    Our 82 year old mother ended up with CHF from chemo for cancer. She wanted the chemo. Mom knew all the risks. Her gentle, caring oncologist actually came to mom’s room and said she was sorry that this happened to mom. Fast forward after a month of hospitalizations and rehab mishaps. A doctor who had been on mom’s rotation and knew we would peacefully accept hospice when the time came, said to me one day, “We’ve already almost killed her twice. I think it’s time.”
    I was given the gift of being with her at home when she breathed her last. But all that would not have happened if our whole family had not already been vocal and communicated our end-of-life wishes.
    In closing I’d like to quote a Jesuit nurse. He will do all he can to help others. But, “If God wants you dead, I can’t stop that.” Peace, joy, love, and laughter to very end.
  18. Eric Miles says:
    My grandfather recently passed at the ripe old age of 93. Over the past decade he had survived several major surgeries that almost claimed his life, including bovine heart valve replacement (3 total surgeries for that one, after a wound site infection) and for colon cancer. With each major medical procedure, he was definitely granted a few more years of active life, including the chance to meet my daughter, his great-grand daughter.
    But this last round, he got sick and once the feeding tube went in… he was pretty much over it. After the tube came out, he wanted three things: family, chocolate and morphine. He died liked he lived, happy.
  19. loren says:
    you don’t know how many times I have stated starting before certain procedures e.g feeding tubes -”don’t ever let anyone do this to me!” Live life to the fullest, take care of your after life concerns, i.e., hope in the resurrection, etc., and then die. there are much worse things. A near death illness made this very real to me. LH
  20. Henry Baggins says:
    I love see the “all knowledgable” RN’s on here spouting off about the lack of proper informed consent and care provided by MD’s.
    As always, you can count on a nurse to complain, bitch, whine, and tell everyone how wrong the doctors are/how right the RN’s are…..until something on the floor/ward/ICU/ER/OR actually happens….then “its not my fault, im just a nurse!”
    • Edward Parker, Jr., MD says:
      My stepmother died with inadequate pain relief during her last week of life in a state where I was not licensed to practice medicine. I had to speak firmly with the hospice staff to get my mother’s doctor to increase her pain med. We even hired someone to push the button every 15 minutes on her drug-delivery machine during the night while we tried to get some sleep. This gave my mother extra pain medicine. When she woke up about 10:00 AM, she felt better and with less pain than she had had in two weeks.
      My advice is to stay out of Catholic hospitals if at all possible if you are dying. The nurses and Catholic doctors will look over you like a hawk to make sure you don’t give more than the usual amount of pain medicine. Not all RNs or MDs in Catholic hospitals will try to take your license, but some are religious freaks who think they are doing God’s work by making you suffer during your last days.
      Second, be very aware of oncologists and radiation therapists. Some of these folks are charlatans who will treat you right up to your last day of life, provided you still have insurance or personal coverage.
      Third, every patient needs an advocate (ombudsman) whenever they are in a hospital.
      Fourth, out of sight and hearing of ICU nurses patients may make their wishes known to their doctor that they want everything possible done to save their lives. Families sometimes ask this as well. (I know this has been covered already.) Doctors don’t always think it is reasonable to do horrendous surgery or chemo/radiation Rx. Maybe under Obamacare they will be told they are not allowed to do ANYTHING once you reach a certain age. This worries me as I am 73 and in good health. Will I be deprived of any therapeutic Rx in the future?
    • John says:
      Agreed. I almost had a bunch of nurses kill me following surgery. I kept telling them to ask the doctor to switch me from dilaudid to morphine for pain maintenance following surgery because I was reacting badly to the dilaudid.
      They decided in their infinite wisdom that they knew better, and didnt forward my request to the doctor. Because they thought the morphine would be more habit forming.
      It wasnt until they almost went back in that my surgeon heard my request straight from me, and we both discovered the nurses and had simply ignored my request.
      I should have sued the nurses.
      • barbara says:
        Sad to hear your story. Not all RN’s act like that. Working many years in PACU, I considered myself to be the patients advocate. For pain issues, a quick call to the surgeon & anesthesiologist , suggest a Pain Consult, all with the goal of patient comfort. Changing from Morphine to Dilaudid was done within minutes, with MD guidance. I cannot decide which drug to administer without a doctors order, but yes, your doctor needs to be informed, that’s my job
      • Stef says:
        umm weird- i don’t believe i’ve ever hear of a story like this before.. and how long did it take you to talk to an MD??? bc they should have been rounding on you every day???
  21. Dylan says:
    Very interesting and insightful read.
    I feel like there’s another major factor overlooked by the article. People don’t want to die. I mean, most people REALLY don’t want to die (nor do they want their loved ones to die). I think people who work where they see death all of the time (like in the medical field) are far more likely to realize and come to terms with their mortality and realize death is an inevitability. I think that’s another factor at work here.
  22. Liz says:
    As a Peds nurse for many years . . . I have some to call the long-term, PAINFUL, futile treatment of infants and children as medical child abuse. If any other group of people (aka a cult) did half of what we do to torture these poor kids in the name of “healthcare” they would be reported to DHS and they would be jailed. Just because we can, doesn’t mean we should, and we can’t fix everything. I agree that the public has unrealistic expectations of healthcare, I also believe that the “I should have Died” reality TV shows feed into this, and we have raised a generation of people who have never heard the word “no”, got a participation trophy for sitting on the bench, and think they know more than the MD’s and nurses because they can “google”. ICU nurses are leaving hospitals in waves because you can only handle the stress of experimenting on patients so long before the unethical aspects of our current healthcare system burn you out. To understand how MD’s and RN’s helped with Nazi war experiments we have only to look at what goes on in our own ICU’s today . . . .
    • John says:
      Given that most doctors do nothing but google or poor through physician symptom checkers, then I think most patients are nearly as smart as their doctors. All GP’s and internists do anymore these days is write referrals to the specialists.
      • anon says:
        I’ve worked around physicians and am currently a medical student and of all the doctors I’ve shadowed, I’ve never seen one look at Google or a “symptom checker” a single time. The only time I see a physician open a book is to confirm a suspect diagnosis. It’s entirely possible that a physician such as you describe exists, but to say “most” is ridiculous, uninformed, and melodramatic.
      • doc says:
        John, first I was going to attempt to clarify what GPs actually do. But given your level of ignorance, I will not attempt it
      • Noah says:
        John, do you understand how much schooling, studying, sacrifice, and time that it takes to become a doctor? My wife is currently a SRNA, and it completely consumed her life.
        I would love to try and perform surgery on you only using my tablet and google search. Want to let me try?
  23. lauren says:
    Liz, Amen! Couldnt agree more. Death is no longer inevitable or acceptable. I admitted at 94yo woman for heart failure with severe aortic stenosis. Symptomatic for over a year. Average life exp from symptom onset is 2yrs. I explained the plan, get the fluid off, get her comfortable and on stable meds and get her as much time with the grandkids as poss. Re resus status, ‘bring me back’. I explained what ‘do everything’ meant should her heart stop or her breathing deteriorate incl rib cracking, ETT and tying her hands down if she went for the tube. I also mentioned the likelihood of any success being about nil given her heart and kidney disease as well as her age. She and her daughter looked at me like i was from the Fox News ‘death squad’. Like i was withholding the medical magic wand that makes fact irrelevant. Her daughter said no one could predict the outcome. So painful seeing this age group with trach, dialysis and PEG tube but it can be an uphill battle.
  24. John Ballard says:
    This post has to be among the most durable ever to appear at The Health Care Blog. I think it first appeared in 2011.
    For those who want to explore the subject further here are a few of links. This is a collection I put together at a blog now gone silent, but for the moment most of the links still work, including one to an event that Dr. Murray took part in last July.
  25. Sadie McFarlane says:
    Wonderful article. My dad spent several miserable years getting dialysis twice a week (they never did figure out WHY his kidneys failed) and one day died during dialysis – and just like the article said, they broke his ribs resuscitating him. He was SO MAD, because he had died so peacefully, and they revived him so roughly. Then he wrote out his directives. Then he actually asked mom and myself if we minded if he just stopped treatment and died – and was both surprised and relieved that we did not. He died – peacefully and in his sleep – two weeks later. My mom died the same way a few months after him. I felt that they were truly blessed! What a horrible waste of money and resources and lives and happiness, that we feel compelled to prolong life NO MATTER WHAT. And all of this certainly isn’t making American Health Care any cheaper. We need a major revision in our thinking on the subject – so this article is right on target!
  26. Mke says:
    It’s is a very personal thing and this article makes sweeping generalizations and assumptions. I am a medical professional and I spend my days with many health care colleagues. Each one would likely do a different thing in the same circumstances.
    I personally love my life and family and I would fight for every moment, kicking and screaming the whole way. I refuse to, as Shakespeare said, “go quietly into the night.” I will suck every moment out of this life and I will fight to spend as much time in it as I can, thanking the powers that be for giving it to me and blessing me with everything in it. I think that is the least I can do for the gift that has been given to me. I believe in fighting for what you want, taking the bad with the good and recognizing that without the bad, all that good would seem pretty mundane. Just my thoughts.

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