"Doctors Don't Overtreat Themselves"
Crid (via Radley Balko) pointed me to this compelling piece on Zocalo by Ken Murray, "How Doctors Die" -- 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.
...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.
There's a note in my wallet, and on file with Kaiser, saying I don't want to be kept alive as a human turnip, but I'm tempted, for the first time in my life, to get a tattoo.
Related, by Hitchens.
I'm visibly healthy today, but it took a sextuple bypass operation to achieve. My first thought when I came out of surgery was, "This is SO not worth it!" I had no idea it was humanly possible to experience such abysmal misery. I would not inflict this ordeal on anyone I care about. The doctors are completely unprepared to deal with the emotional havoc they create.
Jefe at December 8, 2011 11:12 PM
Yoosta date a nurse, and once talked with her and her friends about getting a tat. They said that unless there were paperwork on file and close familiarity with the patient, it would probably be ignored. I suppose you could get a whole contracted scratched out if you wanted to, people are doing that anyway. But the shame would kill anyone too old for the fashion....
Crid [CridComment at gmail] at December 8, 2011 11:38 PM
PS- Link by Balko.
(Compensatory good cheer)
Crid [CridComment at gmail] at December 8, 2011 11:53 PM
As a physician I can very much relate to this. My dissatisfaction with having to provide futile care to so many is what made me switch specialties from Internal Medicine to Pathology. I've never looked back.
DrMaturin at December 9, 2011 6:53 AM
I think about this often. If I'd had sole control over my parents' medical care (instead of sharing it with my sister, who can't let go of anything), they would not have died the way they did -- which is, to say, in misery and prolonged pain.
I know neither of them would have wanted to suffer, but when you don't leave anyone in charge, hospitals tend to err on the side of life, even when that life is hopeless.
If you don't want to suffer needlessly, have a chain of responsibility for who gets to make decisions. Have a living will and a health care proxy in place before you are sick, and make sure everyone involved has the paperwork that names them as such. Don't ask people who aren't emotionally equipped to let you die. And ask intelligent people. With no insult meant to my sister, she never really understood the details of what was happening to our parents, so she kept approving retarded procedures.
Their experience was the opposite of my husband's grandmother's. When her cancer returned, she knew she didn't want treatment. She took total control of her own care, including naming people who would be in charge when she lost that capacity. In the end, she died exactly the way she wanted to.
Of course, in the end, she died in a lot of pain, too, despite all the medication and preparation. Sometimes there's no way around that.
MonicaP at December 9, 2011 7:41 AM
My great-grandfather in England was euthanized at home, a decision by his doctor and his family. He went very peacefully.
My Mom has been in a catatonic state in an Alheimer's unit now for 3 years, at a personal cost of $7,000 a month. She and my Dad lived very frugally, only taking one major European vacation when I was growing up. It's terribly sad, and to some degree a lesson I have tried to incorporate in my own miserly existence. Spend it now while you can enjoy it.
PS- Great, thoughtful post, Crid and Amy.
Eric at December 9, 2011 7:46 AM
Damn Crid- a two-fer. Voodoo slide whistle was hillarious.
Eric at December 9, 2011 7:56 AM
Amy Alkon
http://www.advicegoddess.com/archives/2011/12/09/doctors_dont_ov.html#comment-2844343">comment from EricSad, Eric. (" She and my Dad lived very frugally, only taking one major European vacation when I was growing up.")
I think it's important to not live beyond your means but also to live a life of balance. I wrote about that a bit here:
http://www.advicegoddess.com/ag-column-archives/2011/11/all-work-and-no.html
Also discussed it on my radio show with Dr. Scott Barry Kaufman:
http://www.advicegoddess.com/ag-column-archives/2011/11/all-work-and-no.html
Amy Alkon at December 9, 2011 8:43 AM
I used to do inventories for a living--one of my specialties was pharmacies, so after a while I got to know many of the local pharmacists.
Pharmacists, it turns out, as a group outlive every other profession. And they also refuse to take most of the drugs they dispense. No lie. Asprin, ibuprofen,and Vitamin C are pretty much all most of the crusty old pharms will take. Some of the younger ones will take more vitamins.
I have to believe there's a correlation.
Also, one of my uncles is a world famous cardiologist and he's always used massive amounts of butter, stating there's no correlation between cholesterol and heart disease. And thanks to Gary Taubes and others we now know the truth about that.
We always need to ask health professionals if they follow their own advice, as many of them will just dispense "common wisdom" so as not to be discredited in the medical community.
Ever so slightly off topic, I know.
deathbysnoosnoo at December 9, 2011 8:44 AM
ObDieInSleepLikeMyGrandfatherJoke
jerry at December 9, 2011 8:51 AM
> ObDieInSleepLikeMyGrandfatherJoke
PropsForConcision
Crid [CridComment at gmail] at December 9, 2011 9:08 AM
Thing about those Alzheimers facilities is, they're the envy of human history. It sucks to have to have them and it ess yoo see kay sucks to not have one available.
But there's much more to life than preparedness, even for something like that, which could torment the kids who have to care for us. I agree with you, we have to live well enough to be glad we went through this.
Crid [CridComment at gmail] at December 9, 2011 9:14 AM
> she died in a lot of pain, too, despite all the
> medication and preparation. Sometimes there's
> no way around that.
I used to think otherwise. (Remember Oz? "Poppies!... Poppies!...) I always figured you could just open up the candy store.
But yesterday I learned there are some pains, such as the poison sting of the platypus, that can't be squelched by opioids.
Sucks to be human.
Crid [CridComment at gmail] at December 9, 2011 9:35 AM
Offtopic / More grim stuff— Could someone please put this in their mouth and get back to us about what it tastes like? 'Kay, Thankee
Crid [CridComment at gmail] at December 9, 2011 10:52 AM
Maybe health insurance companies can offer a deal: lower premiums in return for people agreeing they'll only get hospice care under certain conditions.
Kind of like free market death panels.
Ori Pomerantz at December 9, 2011 11:05 AM
Isn't that kinda how it works now WRT excluded conditions for coverage? Every year, just after the notice of higher rates, the insurance company sends a list of new exotic cancers for which they'll not provide medication.
(Not an expert on this)
Crid [CridComment at gmail] at December 9, 2011 11:19 AM
By rates I meant "premiums". (See? Not an expert)
Crid [CridComment at gmail] at December 9, 2011 11:21 AM
No, because right now the insurance company doesn't give you an option to pay extra and have those cancers covered.
Ori Pomerantz at December 9, 2011 11:34 AM
You can but different insurance, right?
We don't as people selling minivans or pickups to also deliver sport coupe performance: Different product.
Crid [CridComment at gmail] at December 9, 2011 11:43 AM
Buy. You can buy different insurance.
Crid [CridComment at gmail] at December 9, 2011 11:44 AM
offtopic / Crid: my first look at those towers brought to mind an elephantosis-like tumor. About 5 seconds later I made the 9/11 connection. Real fucking tacky.
Eric at December 9, 2011 12:06 PM
I'm stubborn. If there's a reasonable chance that I'll recover well enough to write code, waste time on the Internet, and listen to music, then break out the scalpels. But yeah, at some point you (or someone you trust) has to weigh the lifespan and quality-of-life benefits against the pain, effort, and yeah, the $$$. I have no more desire for my body to outlive my brain than Amy does.
I will add this: I think a lot of people facing terminal illness demand more treatments in part because they suspect that they aren't being told about all the options, either because the doctor isn't familiar with the available treatments, or because the information is being withheld from them. Most of the latter is urban legend, but every once in a while, you come across something that makes you wonder. If Obamacare actually becomes law, that fear will increase a million-fold.
Cousin Dave at December 9, 2011 3:03 PM
Where to draw the line isn't always clear, either. Like with my father. He had an operation to remove part of his intestines. After that, his heart began to fail. His doctors suggested a pacemaker. We asked ourselves, "Did we just put him through that to deny him a pacemaker?" And when family members are having doubts, doctors often push for the medical solution. Or assume, of course you will do it, which is coercion of its own.
MonicaP at December 9, 2011 3:14 PM
> the doctor isn't familiar with the available
> treatments, or because the information is being
> withheld
Well, there's a, um, diversity of medical talent out there. Problems like this happen more from incompetence than venality. And patients bring incompetence into the office with their own insights, so information gets "withheld" in some goofy ways... Ever hear about that woman who was constipated?
I did that once, trying to show off. In a car crash at age 13, a kidney got knocked around a little bit... The doctor said he found some blood cells in my urine. Two weeks later, talking to a different doctor, I told him they'd found some red blood cells in the urine... But as I sat there and thought about it, I couldn't remember whether they were reds or whites. Well, it probably didn't matter. But I'd have felt foolish for passing the wrong information if it HAD mattered.
Saying exactly what you really know and nothing more and nothing less is a life skill, one I've practiced in a career working with engineers. (And again, engineers at different levels of competence.) If you're going to approach an expert, tell them the symptoms and let them do diagnosis. If you know the expert available to you is good for nothin' anyway, you can save yourself all kinds of trouble.
Meantime, I sympathize with anyone who's had to care for an elder in decline... And I fear all of you have or will.
Crid [CridComment at gmail] at December 9, 2011 4:05 PM
> ObDieInSleepLikeMyGrandfatherJoke
PropsForConcision
When I die, I want to go peacefully like my Grandfather did, in his sleep -- not screaming, like the passengers.
——————————————————————
I'm of the mind that if I come into the ER as a result of a car crash or similar acute injury -- I want medium level resuscitation efforts as long as I will have something substantial above my eyebrows.
Jim P. at December 9, 2011 5:17 PM
I'm of the mind that if I come into the ER as a result of a car crash or similar acute injury -- I want medium level resuscitation efforts as long as I will have something substantial above my eyebrows.
Unfortunately, this is an example of the line not being so easy to draw. Doctors don't always know how you'll recover or whether. You might be fine, or you might be a turnip.
MonicaP at December 9, 2011 8:01 PM
My father, when he started to become ill, he looked me in the eyes and told me point blank that he wanted everything medically possible to keep living.
Later, after the lung cancer and the chemo, after two strokes, I'm still not sure that the DNR that the family decided upon was what he wanted. No one wanted to prolong his suffering, but I wish I knew for certain that was what he wanted.
I wish he'd have set something up before that, instead of wanting to spare my mother the loss of control. I'd feel better now.
Cat at December 9, 2011 8:20 PM
I agree with the general tenor of this discussion and the article. However, I would definitely not include CPR in any list of "heroic measures". It's not true that, if done right, it breaks ribs. I could be wrong on that. Even so, a broken rib or two, while painful, does not bring anyone down to the level of quality of life that is not worth going through. It'll heal in a few months.
If all I need is CPR, for God's sake, give me some damn CPR.
As for the other stuff, I generally agree with the rest of the crowd. I'm just puzzled about the inclusion of CPR in the article. That's hardly an extreme measure.
whistleDick at December 9, 2011 8:30 PM
"If all I need is CPR, for God's sake, give me some damn CPR."
Every time I go into a public place I look around to see if there is an AED machine somewhere. I'm waiting for the day when they get cheap enough and maintenance-free enough that you can afford to keep one at home. At that point, CPR becomes almost obsolete.
Cousin Dave at December 9, 2011 8:42 PM
> My father, when he started to become ill, he
> looked me in the eyes and told me point blank
> that he wanted everything medically possible
> to keep living.
Sweet Jesus. Last time heard anything like that, it was a satire, one of my favorites:
Leyner.
Crid [CridComment at gmail] at December 9, 2011 9:29 PM
I took a CPR class as part of my requirement for dental school and you would be absolutely amazed at the amount of force that it takes to do a chest compression. Pivoting from the hip, pounding with interlocked fingers - it's nothing like tv. It can do more than just break a few ribs - it can break your sternum especially if you are doing CPR on young children or elderly patients. That is dangerous in and of itself.
Katie at December 10, 2011 2:41 PM
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