Thursday, March 8, 2012

Why Many Doctors Die Differently

How do doctors prefer to die?  Are they in a better place in their last days than non-physician patients are?

Ken Murray, retired clinical assistant professor of family medicine at the University of Southern California, recently wrote about this issue in the Wall Street Journal in a piece called: “Why Doctors Die Differently”.

Dr. Murray wrote about a 68-year-old physician who, when diagnosed with pancreatic cancer, immediately closed his practice, focused on spending quality time with family and passed away at his home several months later.  The physician opted for no chemotherapy, radiation or surgical treatment and Medicare did not spend much on him.

Dr. Murray also cited the case of his 60-year-old cousin diagnosed with lung cancer that had spread to the man’s brain.  Aggressive treatment including up to five hospital visits a week for chemotherapy might have given the man another four months to live.  Knowing he wanted a life of quality and not quantity, he opted against advanced interventions and to take some medication by mouth for brain swelling.  He moved in with Dr. Murray and the family enjoyed the next eight months, during which their cost for care was about $20 – for the pills.

This is a good conversation that has to happen between doctors and their patients. Sometimes doctors are unwilling to limit a patient’s access to something even if they know it’s not going to benefit the patient because they are reluctant to withhold care and leave the patient without hope. But doctors who are in the same situation - facing the end of life – don’t have this burden. They know the evidence already, so as Dr. Murray writes, they often don’t take questionably beneficial care and seek a death that is as comfortable and respectful as they can get.

As a physician, I’m not sure that this is “routine”, but that’s what I’d want for myself.  Our health system’s vision phrase - “To every patient, every time, we will provide the care that we would want for our own loved ones” (See: Our New Vision, Our New Plan to Get There suggests a choice.

As physicians, we really need to present the best evidence to the patient and make sure that the patient has understood…..and then let the patient choose. When care is not likely to help, we need to make this clear to the patient. We need to have this dialogue with members of our community. Physicians have to be unburdened of the belief that unless they are doing something that somehow they have let their patient down.

We are trained to be healers – and the proclivity to action is part of being a healer but the tenet primum non nocere (“first do no harm”) must also be kept in mind. When our actions have a very low probability of benefiting the patient we need to avoid misleading the patient. Although the societal cost of providing care that is unlikely to help is immense, it is not the job of a physician at the bedside of an individual patient to limit that care. It is her job to assure that the patient knows the probability of cure and the risks associated with the treatment. I believe that as we get better at having conversations with patients about what they want at the end of life that the cost issue will take care of itself.

Shared-decision making is an essential part of today’s care planning.  Some medical schools now even have formal classes in shared-decision making.   Certainly patients are wondering, “What is this likely to mean to me and my case?  Am I going to live longer, am I going to be pain free quicker, am I going to have a better quality of life over my last few days?”, and those conversations with doctors need to happen.

While these conversations are necessary they are not easy. Some doctors are naturally better at it than others. Those who are more empathetic and better able to connect with the patient begin the conversation more readily.

With the aging population and with healthcare costs skyrocketing, this is the right time for the American people to become engaged. We should never withhold care that will save life but it may get to the point that since we are providing care for patients who will not benefit that we may not be able to serve some who will.

What are your thoughts on the issue of shared decision-making with end of life care?  

Kudos to Emergency Department Staff

I have to give kudos to our Emergency Department staff yet again! GBMC’s Rapid Response Team recently brought a patient to the ED who was in another area of the medical center and experienced severe cardiac issues. The patient was brought in with a “STEMI”, a clear heart attack. Within 16 minutes the patient was stabilized and transferred to the cardiac catheterization lab at a nearby cardiac intervention center to open up the blocked arteries. I’m told this is the fastest we’ve ever gotten a patient to the cath lab.  Rapid transport to a healthcare facility capable of performing percutaneous angioplasty, is critical to the survivability of such a heart attack. Experts say the sooner that a patient is treated to relieve the blockage causing the STEMI, the better the heart muscle will recover. Great job to the team who made sure this patient had the very best care possible and treated him the way they would want their own loved one to be cared for.

1 comment:

  1. I read this article in the WSJ too. While I agree in theory, the reality is that rational, reasonable family members become less so when a loved one is dying. My stepfather had a Whipple procedure in 2001 (in another state) and became septic. Over the course of five days he had every intervention known to medical science at the insistence of my mother and stepsisters. The doctor kept saying, "everything is reversible" as my stepfather's systems failed one by one. Not a helpful comment, to say the least. They asked my advice, but even if I'd been completely truthful with them, they wouldn't have accepted it. They needed to feel that everything medically possible had been done for him so that when he died (which he did), there was nothing left that could have been done, and that prevented them from feeling like they contributed to his demise ("we should have, we could have, why didn't we try..."). And what did my stepfather want? Who knows? He was in an altered state and couldn't make his wishes known. It's the perfect example of why you need a Living Will.


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