Considering How doctors die: please, NO CODE
Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.In a remarkable article, Dr. Murray share considerations on dead, CPR efficiency and DNR orders. “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.”
Below, as we can read in zocalopublicsquare.org, Murray’s words and some of the comments to his article.
How Doctors Die
It’s Not Like the Rest of Us, But It Should Be
by Ken Murray
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.
*Photo courtesy of patrick.ward04.
Comments (a selection) – ESSENTIAL READING
- HopeSpringsATurtle says:
Virtually every healthcare profession that I know has a “DNR” order as part of their medical power-of-attorney instruction–as do I. Hundreds of millions of dollars are wasted each month to keep people alive with a terrible quality of life when those same healthcare dollars could save the lives of people who have a meaningful chance of recovery and good to excellent QOL. Every person needs make arrangements for what should–and shouldn’t–be done if faced with catastrophic accident or disease. Please consider getting a medical power-of-attorney or living will if you don’t already have one. Thanks.
- Darryl Curtis says:
The most important point that the article makes…or implies…is that death is inevitable, regardless of the heroic measures that one tries to defeat or avoid it…
It is impossible to actually know the outcome of any treatment given to a person in the throes of death…sometimes, the treatments return the person to a viable quality of life…sometimes, the treatments only produce temporary agony before the inevitable end…
It is impossible to know, when authorizing or not authorizing treatment, which outcome one will receive…
So, to authorize treatment or to not authorize treatment is simply a gamble…if you refuse to authorize treatment, there is no evidence that doing so would have helped you…if you authorize treatment, there is no evidence that the agony that the treatment may inflict on you could have been anticipated…
Neither position, authorizing treatment or not authorizing treatment is the correct position in every case…because no one knows the outcome when making the decision…
The correct position is to follow the wishes of the person involved…because in the final analysis, they are going to die anyway…
- Doc Slagathor says:
I am a family doc and have worked as both a hospitalist and small town family physician. I think more patients and families understand the meaning of futile care now than 10 years ago but we still have a ways to go. My relatives in the medical professions and myself are all DNR status as we have seen the misery and heartbreak when we prolong the process of dying. Thanks for the well written article.
BEING PRATICALMatt says:
I think I will get the words for DNR tattooed on my chest, after reading this, just because I know firsthand the lower quality of life one experiences when things go bad in a hospital. Thanks for the insight into this.
- Sarah says:
Thank you for conveying these ideas so clearly and understandable, ideal for those not in health care. I have had to convince family members to let a loved one go because I have seen way too much suffering to allow them to live like that. If they could understand this concept I would not have to be in that position again. I have spent so much time on the education necessary for a career devoted to helping and healing, yet the majority of my time is spent providing and ordering care for too-far-gone patients or patients that will have an very low quality of life, and possibly wish to be dead, because people want “everything done” for their 98 year old mother with CHF, COPD, Pneumonia, end stage dementia, and renal failure.
FROM THE LABAlex says:
Thank you for sharing your very honest insight. As a healthcare professional in the lab, I echo your sentiments.
OTHER MEDICAL OPINIONlooking closely says:
I’m a medical doctor myself and IMO, that last ten minutes of resuscitation isn’t really the issue. Yes, CPR is often pointless, and probably most often so, but its quick, and the patient generally dies right afterwards. It may hurt the doctors emotionally to resuscitate people pointlessly and/or break Granny’s ribs, but most of the time, the patients themselves aren’t aware of what’s happening. . .they’re already unconscious, sedated, or otherwise oblivious.
Its the few days or months of non-quality of life preserving terminal care BEFORE the CPR is done that’s the real potential waste of resources and patient dignity.
By the way, I have a very explicit “living will” and “DNR” (or DNI, “do not intubate”) is **NOT** on it. If I’m in a hospital and my attending MD thinks resuscitating me could add a little quality of life time then I want it done! I do have a clause about “futile measures”, and I’ve had a long discussion about this with my wife (also an MD) who has a good understanding of what I want, and don’t want done at the end.
As to the efficacy of CPR, I think the article understates it. Yes, if someone is brought INTO a hospital needing CPR, they’re probably already so far gone it won’t help. At that point the CPR is mostly “medical theater” just to satisfy family and friends that everything that could be done has been done. Should that NOT be done? Even if someone has a 1 in 50 chance of benefiting from spot CPR that way, that’s likely still worth a shot (given the alternative of just letting them die!).
In terms of INPATIENT CPR, I think the outcomes are much better. I’ve seen inpatients with known disease successfully resuscitated many times. Even though most of them still didn’t leave the hospital alive, at least a few did get a little more time with family members, etc.
Thank you for such a well written piece. As a physician, so much of this resonated with me.
some measure of comfort
Arlene Hazzan Green says:
This article gives me some measure of comfort having watched my mother die of lung cancer. Now, 22 years later I still agonize over not having pursued treatment for her. She was diagnosed in December and died 5 months later having been told there were no treatment options available. I have always regretted not pushing for a second opinion or searching the world, high and low, to find an alternative treatment that would prolong her life. Perhaps we did the best thing after all which was to accept the doctor’s prognosis and spend what little time we had left together with her in relative comfort.
CARPE DIEMsdjrp says:
ken, i have to admit it, we all should be loving our life, we must do it, just cause of our time here… i want you to know this: me, and a lot of people, we suport you, and we all want the same thing: be happy for that moment, we know there is something else before death, and it is better to get there in our time and not to force it
hope you get a nice life and a nice passing trough that pass
EQUALITY FOR ALLJanet says:
Thank you for this article. I too have a DNR in my will, my daughter & others know of this. I want my doctors to be as straight forward as the vets I take my dogs, cats, and horses too.
They do pull any punches and tell me just like it is and give me options and consequences of each one.
THE AESTHETE : the tatooSteve says:
Getting a DNR tattoo is fine. Just make sure you have legal paperwork to back it up.
I hope to execute a full-speed sideways skid into the grave, flat broke, with a guitar in one hand, a drink in the other, a smile on my face, and loved ones cheering me on.
“Time is all you have, and you may not have as much as you think.” –Randy Pauch, from THE LAST LECTURE
A SURVIVOR VIEWDavid Lewis says:
Well written piece which set me thinking whether or not I would alive today to comment if there had been a DNR order available to me.
It was not nice to spend time in ITU.
The bill, if it needed to be paid by me, was > £1.5million
Yet, nearly 4 years later here I am working full time again.
I am very greatful that the ITU team did not give up on me in those challenging first 24h after the 100% aspiration complication respiratory arrest.
On the dialogue: THE ATTORNEYApril King says:
Janet–I’m an attorney in trusts and estates, frequently advising clients on the practical points of (in MN) Health Care Directives. Please DON’T put your DNR/living will/HCD/health care power of attorney, or your organ donation wishes, into your will! By the time your will is found and opened, it will probably be far too late. In MN, you fill out your HCD and give copies of it to the person you designate as agent (discuss it with them, too), and to area hospitals, and to your primary providers and specialists–but don’t leave it in your will (although I do congratulate you on having one–so many don’t even do that).
ON THE DIALOGUE: THE RELIGIOUS POINTLenore says:
I think this was a very effective and well-written article, but it left out one crucial consideration.
It may be obvious, but I think the reason many people fear death, and therefore pursue life at any cost, is because they aren’t sure what will happen afterward. It was terribly difficult to watch my mother die four days after cardiac surgery. However, we were never tempted to intervene more than necessary because we knew, without a doubt, where she was going, and that we would see her again one day. The surety of Heaven is an amazing gift from God.
One of my son’s classmates has leukemia. She comes from a family of great faith, and she is a treasure. She was interviewed for a radiothon for our children’s hospital recently. She said that she wasn’t afraid to die, because she knew where she was going. Imagine the strength and hope that her faith gives to her and her family.
My point is that, yes, we certainly need to be honest and proactive when discussing end-of-life issues with patients and their families, but we should not hesitate to address their beliefs and faith regarding life and death. It may make it much easier for them to reach the right decisions for themselves when the time comes.
DR MURRAY ANSWERING:
Ken Murray says:
Thanks, again, for all the comments!
Marilyn, the process of diagnosis is complex for some cancers. In some cases the only way to get the answer involves major surgery that leaves permanent disability…and who would want to do that if the answer was no cancer? It can be highly frustrating for all involved, and is part of what drives the search for more advanced technology.
Looking Closely, on the CPR front, my point is about unrealistic expectations, such as the 67% success rate of CPR on TV, which people think is what happens.
Jack D, I knew the diabetes patient and her husband VERY well, and the issue seemed to be her confidence that there HAD to be a technological solution, and if something could be done, it should be done. I must also mention that she was a terribly noncompliant patient who took horrible care of herself medically. I do not agree that MOST surgeries are highly risky…most are routinely safe in this day. But there are some situations that are quite predictably likely to go wrong, and when they do, the consequences are not that you go back to square one, you are left with an unfixable problem. I am not against spending money, even huge amounts of money. I am against WASTING money on things that are proven to be useless or likely to produce terrible outcomes. I also notice that your comments are phrased in terms of what you would do for someone else. I do not support that, only doing what a person wants for themselves.
Arlene, 22 years ago is a long time in medicine. The advances have been amazing. Back then, the options were terrible, involving major surgery on the chest, that really did not work. Alternative approaches at the time have not worked out. She probably did the best that she could have, but I know the sorrow of the loss.
Thanks for the pointers, April.
As a family doctor of 34 years, I applaud your approach to this important subject. We MUST continue to EDUCATE patients about the risks vs benefits of treatment. Often, family members will inadvertently act in their own self interest by wishing extension of life for their terminal loved one. Occasionally consultants will act in an aim to “help” the terminal patient until the patient comes to grips with the inevitable outcome.
As as society, we focus on LENGTH of life, not QUALITY of life, and must reevaluate our approach.
Thank you for this article, Gail
THE PARENTSJosh Husmann says:
I understand and appreciate this article. I also have seen the negative side of this within the medical profession. A neonatologist refused to help our son because she perceived him as ready to die. I’m not talking about refusing surgery. The doctor refused to even run blood tests because she disapproved of pricking his foot.
There’s nothing like your son dying in a hospital and his doctor refusing basic treatment, then forcing you to meet with the hospital ethics committee. I actually had a person from the hospital ethics committee come into to talk with us in the final moments of our son dying in our arms.
While medical professionals may not choose heroic care, it’s also not their decision to make for patients. Particularly with infants whose vital signs can change very quickly.
- Dr. Swartz says:
This should be required reading for all human beings.
A POINT OF VIEWDJMoore says:
There’s a huge difference between someone who is relatively young and healthy (relatively in that you might be retired with a chronic disease that can only be treated, not cured), and who could well live comfortably for months or years after a successful resuscitation; and someone like my mother, who is elderly, frail, very ill, and unlikely to survive an aggressive resuscitation attempt with any comfort, or at all. She’s made her preparations, seen her children and grandchildren, is exhausted, and is ready to go.
Our attorney has recommended that we NOT fill out an Advance Medical Directive for Mom. Instead, she’s signed a Medical Power of Attorney, and that person’s judgment is taken to be as strong as her own would be. It seems that the language of many AMDs can be taken by doctors to mean pretty much whatever the doctor wants; better to leave it undefined and make the MPoA agent be the last word.
In our jurisdiction, the DNR is a state form with very limited, relatively well tested language. I’m told it will even stop 911 EMTs from being overly aggressive where not appropriate. Accordingly, she signed one of those when she was admitted to the home hospice program.
Nothing in this comment should be taken as legal advice. I say only what seemed to be best for us.
THE ONCOLOGISTKent Bransford says:
Thanks for a clear, compassionate appeal for rational care for all of our patients.
I’m an oncologist, and your article reminds me of a friend’s mother treated by an oncologist in my own practice, with best intentions… she had metastatic pancreatic CA at 80, not really wanting aggressive care… got the opposite of what Charlie, the orthopod got, for a variety of reasons including default assumptions in the system and physicians wanting to “do something”.
I think it might be worth posing the following questions when we counsel patients, especially with life-threatening problems:
If I wouldn’t accept this treatment, knowing likely outcomes and side effects, don’t I have an obligation to convince my patient / family to NOT to ‘just go along’, ‘give it a try’?
Should the vast majority of oncology patients, for example, have a default or presumed “DNR” status when we approach “the talk” with the onus on the patient to strongly speak out and insist on “do everything, even if futile, even if it is torture”?
How can we “institutionalize” including “the talk”, the recommendation of DNR, right up front when we’re talking about the options for treatment- side effects, benefits, risks? We’re already talking about odds of success, or failure. I know it’s emotional for everyone involved, but we ought to be able to routinely, humanely- include this just like we do “chemo education” for patients starting down a treatment path.
Many docs have an electronic medical record. It should have the capability to check the box, whether code status wishes are documented or not. And flag the patient’s chart if not addressed. Wouldn’t that be nice, to quickly look up a patient’s educated, stated wishes for, e.g. the 76 yo lady with metastatic breast CA you may see in the ER Sat at 11PM?
I’m ashamed I don’t routinely have this discussion at the outset with all my patients. I’d love to see this be the norm so everyone “goes gently”.
- Rohit Bohra says:
Very true and touching. At least in most western countries the concepts of hospice care and DNR/NFR are quite common. In India, it is not legally allowed and therefore it becomes difficult for us in thesae situations. As high end private medical care is relatively new in India, most patients’ attendants start believing that the hospitals are just trying to make money off their tragedy. Their frustration is then vented out on the junior doctors on duty at the time if something untoward happens. Also, medical litigation is gaining a foothold here now so the other thought in their minds is that whatever we are doing is not for the patient’s benefit but to safeguard ourselves. This is an unfortunate scenario
- a nurse turned alternative energy healer
- Nici says:
As a nurse turned alternative energy healer, I am fascinated by the discussion. I am touched by the honesty of the doctors who have contributed. Dying with dignity is everyone’s right.
What amazes me though, is that there seems to be a clear picture that there is either hospital treatment (with all the aspects of associated trauma, huge cost and uncertainty) or death. Is that really where we find ourselves in this year of 2011?
There are so many stories which prove that this is not the case. My favourite one to date is Kris Carr who was sent home with zero prognosis when diagnosed at age 31 with many malignant tumours on her liver. She took her health into her own hands, acknowledging that her poor diet, sugar and caffeine over-use and stress had caused it, and changed her lifestyle, her diet, her attitude and 6 years later she is still around to tell the story. Read her inspirational and humerus account in her book Crazy Sexy Diet. It is a testimony to the human spirit, to never give up, even when your doctor tells you that you are going to die.
If I had cancer, I would not go to my doctor or hospital. I am quite convinced that these dis-eases are caused by our lifestyle and emotional stress, therefore can only be healed by a drastic change in lifestyle, NOT radiation which poisons our system and chemicals/drugs which are so toxic they allow the body a slim chance of survival.
We need to be responsible for our life style, not seeking desperate measures when faced with death.
- Altaf says:
I completely agree with this article, no one has live for ever. All of us have to leave this world when our time is over no one can add a Second to our life.
PSYCHOTHERAPISTPastor Rob says:
Thank you, Dr. Murray, for this insightful, powerful article. Years ago, before I left my psychotherapy practice to finish seminary, one of my dearest friends and closest colleagues, a psychiatrist, was married to a wonderful woman of many years who was an oncologist. I still remember the day when she called me and asked me if I could come over to talk with her and to be there with them when she broke the news to her husband that she was diagnosed with ovarian cancer. She had concluded, based on her own expertise and consultation with colleagues, that treatment might prolong life a short while, but that there would be many side-effects to the treatment and that there would be low quality of life. Therefore, what she wanted to express to her beloved husband of many years, is that it was her wish to enter hospice care — palliative, rather than curative care, that she wanted to die with dignity, with her family and friends near her, in the most comfortable surroundings possible. Since she and her husband were among my closest friends, I, of course, offered support to both. Her husband was horrified at the news and struggled with the coming loss, but he also supported her decision and actually concurred with her reasoning after they had some private discussions.
I remembered this when my own mother died within six months of her diagnosis with Ovarian cancer on my birthday back in 1997 and again earlier this year when my 87 year old father’s skin cancer matasized to his lung and was pushing on his heart, restricted his breathing and took his life within two weeks of his admission to the best heart hospital for what was initially believed to be heart problems (even though he had no such history). The wonderful cardiologist and his longtime oncologist (who I knew for many years through his repeated treatments, remissions and flair ups) broke the news to both of us. As the only child, with physical disabilities of my own from birth, it was such a challenge even though my Significant Other was there for support to both of us (and is such a Godsend in dealing with all those wonderful issues that follow in resolving a complicated estate). It’s true, the doctor’s reminded Dad and I, that there were treatments that they would encourage if I, 48 at the time, were facing the diagnosis, but that he was simply too old and frail to probably survive the treatments themselves and, even if he managed to do so for a while, there would be NO quality of life. Within 23 hours of his admission to a wonderful inpatient hospice, Dad died after some final discussions with my partner and I and a private discussion and goodbye to me. I was so impressed with his cardiologist that she’s now MY cardiologist and so impressed with the care he received during that last day at hospice (they expected 2 weeks maximum) that should I face the situation some day, I would choose that surrounding if home is not an option.
During one CPE (Clinical Pastoral Education) sequences, I was a hospital Chaplain at one of those facilities where the preferred method to break news of death or impending death to family members was though Pastoral Care with the physician also present. I saw so many times when some family members desperately wanted the physicians to continue some treatment that would lead to more physical life sometimes even if the quality of life would not be good. I know how much psychological and spiritual pain the patient (if aware) and family members went through, the medical, physical pain not withstanding. I know, from the medical professionals, the emotional and spiritual challenges THEY experienced as healers who could not rescue or provide effective quality-of-life prolonging treatment.
In my other CPE, I worked with patients who were dealing with end-of-life issues from AIDS and I remember to this day something in a book on HIV by a San Fransisco physician, Mary Romeyn. To paraphrase, she says that at the later stages of the illness, when the HIV medication cocktails cease to be effective and the side-effects become too severe compared to the quality-of-life outcome, the patient has the right to say when enough is enough, to stop taking the “cocktail” and to focus on medications to relieve symptoms rather than stopping the disease process. This has stuck with me throughout years of ministry as assistant pastor and then senior pastor at various congregations, in my “sick calls” to hospitals and in my counseling terminally ill congregants or providing spiritual support and counsel to their loved ones.
I have come to the conclusion that we are to love and live life abundantly and that, at some point, that also means knowing when to “let go” and prepare for “death”, which I really see (as an ordained minister, as a person of faith) as a “transition” into the next adventure: going home, “glory into glory” as an older African American church lady I knew used to say.
- jOHN says:
Great article…Should be published on the frobt of all newspapers..Mandatory reading.
I am an E R RN. I see first hand on a regular basis, how families want to drag their loved ones thruogh the so called medical mud just to “keep them alive”. I think what also needs to be said is that when it comes to dying, WE are the scared ones. In that I mean the family. No one wants to loose a loved one, but who is better off ? Us or the paitent that has just been wrecked by CPR,INTUBATION and all the other meds given in a code.
also it seems to me that people that are responsible for the bill do seem to reject the “heroic measures” more than families that never see a bill at all.
just my opinion
CARDIOLOGISTSMohammed Najeeb Osman says:
This article was forwarded to me by a good friend of mine and I am so happy he did! Both of us are cardiologists sub specialized in various fields – and as such, we know exactly what you are talking about, while fully agreeing with! It is a pity that patients in most of the situations have no real information regarding the realistic outcomes and doctors do not spend sufficient time explaining the options or rather lack thereof – fearing “not doing everything possible” or wanting to make more money. In this era of information literally on finger tips, patients’ dear ones would be asking all sorts of questions, from their eagerness of getting their loved ones better, albeit coming from their rather half-baked knowledge, and I feel it is our responsibility to take time and explain to them in as layman terms as possible, the cons of the treatments, as well as one does explain the pros!! I feel it is a great disservice to fellow human beings, when politicians start demonizing any attempt by the government to encourage physicians to have more discussion with family regarding medical care, especially in critical and potential end of life situations, painting them as attempts to kill off your grandma!!
And certainly, I would love to walk gently into that good night!
As in :
Thanks Ken Murray & Zocalopublicsquare.org.