How Doctors Die

June 4, 2012

> Hi,> here is an article that I think will speak to many of you!> > The article is below in the body of the email, as is the link.> > Pass it on!> And fill out your preferences for your health care - Five Wishes :> www.agingwithdignity.org/forms/5wishes.pdf> > > > Here is the link: http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus/> > And here is the actual 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.

June 4, 2012

Wonderful...!---Sharlene

>

> > Hi,

> > here is an article that I think will speak to many of you!

> >

> > The article is below in the body of the email, as is the link.

> >

> > Pass it on!

> > And fill out your preferences for your health care - Five Wishes :

> > www.agingwithdignity.org/forms/5wishes.pdf

> >

> > Here is the link:

http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/ne\

xus/

> >

> > And here is the actual 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.

>

June 4, 2012

5 Wishes looks to be a useful document and I also had not heard of it.

I have found the POLST forms helpful: http://www.ohsu.edu/polst

Interested in people's thoughts on the similarities/differences if they have compared the two.Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA 92617PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

www.SharonMD.com