09 December 2011

How Doctors Die

No CPR
A must-read piece from 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.
Worth the full read.

And so true. I've joked about getting the above tattoo when my times comes. (I would quibble that the modern CPR success rate is better than infinitesimal, especially with hypothermia, but it still ain't great.)

It may have to do with the time I spent on the onc ward as a med student, or it may be because my mother in law is a cancer counselor, but I have the dubious distinction in our shop for being the doc most likely to make a palliative care consult and/or make a patient "comfort care only" prior to admission.

Personally, I think it's because I am lazy, and like any other person I take the path of least resistance. Which isn't to say that I don't want to do the work of keeping someone alive -- not at all. It's that I find it so traumatic and horrible to subject a dying person to that sort of abuse that I'd rather face the family and have the "We need to talk" moment. It's not less work, but it's less awful.

I wish more ER docs took the time to do the same. I know what I want when my number is up, and I don't want a week in the ICU on triple pressors.

6 comments:

  1. Remember, the younger you are, the more you NEED to have your desires regarding end of life care spelled out in a living will and/or a document like Five Wishes (FiveWishes.org). If an accident or illness makes it impossible for you to make your own healthcare decisions, who will make them for you? Do they know what you want (and don't want)? Are you sure? Have the talk!

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  2. But see, up here in Canada, even if you have a living will, your POA can turn around and disregard it. The living will is merely a suggestion of what you'd like done, albeit if it becomes apparently clear your POA is acting against your best interests, the living will can be used as evidence of this.

    I've already told my girlfriend, brothers, and parents when my time comes to make sure they never get a tube down my throat, and to avoid any medicines with the word "Dope" or "Levo" in them.

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  3. Good for you. I think a lot of doctors THINK they're telling the family that the patient is on the way out, but one way or another that's not the message the family gets. You really have to rip the bandaid off.

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  4. It always bothers me that more ER docs don;t think of having that talk with family in exactly the same way. I have watched countless ER docs avoid that moment, hoping someone else would take responsibility for it, sometimes even giving false hope, and thus subject some poor slob to that week in the ICU on triple pressors, a vent, continuous dialysis and who knows what else.
    I once even got in (just a little)trouble for telling a doc to grow a pair. I learned my lesson about saying it outloud, but there has not been an ER I've worked in where I haven't thought it quite loud.

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  5. Thanks for the posting, and the comments.

    Remember that my comments on CPR were in the context of terminal patients.

    I've been gratified by the discussion this piece has generated on the subject of end-of-life choices, and it was enjoyable to write.


    Ken Murray

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  6. Reading this, it reminded me of another story http://www.nytimes.com/2010/04/04/health/04doctor.html?pagewanted=all
    Guess in the end, we may or may not stick with our DNR decision.

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