Over the last few weeks, I have had many elderly patients with multiple co-morbidities being admitted under my care. Call me conservative, but right from those days I had always believed in informing the relatives the hard truth. I will inform them from day one itself that there is nothing much I can do and very high chance that the condition will deteriorate. I will inform them the possible options that are available. These are patients who are suffering from irreversible medical conditions and have reached their terminal event. Ventilating these patients will never be my option. You just have to put yourself as the patient and decide what would you want at that time.
There are many doctors out there who will listen to relatives than making a sound clinical decision in the best interest of the patient. I have had doctors who ventilate a terminally ill advanced cancer patients and even a patient who has been bed bound for the last 2 years due to a stroke. Will this change the outcome ? It will only prolong the suffering of the patient. In private sector, it is just a waste of money for the relatives. No matter how painful it is to say that we can’t do anything for the patient, it has to be done. Remember what this doctors said in his last speech ?
Let me give you an example. I just saw a 81-year-old frail looking lady. She was diagnosed to have Ca Head of Pancreas with biliary obstruction and liver mets 6 months ago. If I was the doctor, I would have just suggested stenting of the bile duct and go for palliative care. Unfortunately, someone out there in a neighbouring country decided to go for a major surgery (Whipple’s procedure) after subjecting the patient to ERCP, EUS and tissue biopsy. Intraoperatively, they felt that it is at an advanced stage and decided to do a triple bypass surgery instead. Logically speaking, why did they even attempt the surgery in a 81-year-old lady with the CT scans already showing metastasis ? Is it because the family requested or someone wants to be a hero? A good doctor would have just advised her to go for palliative care and symptomatic relieve. Now, the same doctor who did the surgery told the patient to go back and rest at home as nothing much can be done!! Shouldn’t this been told when the diagnosis was made? The story is just for everyone to ponder upon! The family spend huge amount of money for something that did not do any good for the patient.
The article below was circulated in Facebook and emails about a month ago. It appeared over here. Every budding doctor and doctors themselves should read this article below, written by a family physician. It is the truth and definitely I do not want someone ventilating me, putting me on a tracheostomy tube, NG tube and being bed bound for the rest of my life, if I survive. I rather die peacefully. What’s important is that my family will be taken care of by leaving behind adequate insurance and a will. As I cross halfway of general life expectancy, I have done all those.
Well, after 16 years of service as a doctor and almost 3 years of being “on-call” daily in a private hospital, for the first time (except Singapore) I am bringing my family for an overseas vacation. I could not afford to do this for a long time. Thus I will be off my blog from 30/05/2013 till 9/06/2013. It is a long trip to the Theme Park city of the world. …………………
How Doctors Die
It’s Not Like the Rest of Us, But It Should Be
by Dr Ken Murray
Years ago, Charlie, a highly respected orthopaedist 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.
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