Saturday, April 7, 2012

How people die, and how should we?

On January 4, 2012, "How Doctors Die"; post on Zocalo Public Square by Ken Murray, I called attention to “How doctors die: it’s not like the rest of us, but it should be” a very articulate discussion by Dr. Murray about how the physicians he knows generally eschew “heroic” interventions at the end of life. This is because they know how futile, and often painful, such interventions can be and how disruptive they can be of the little time that they have left. Physicians know more than most other people about what is likely to work and what is not; they also know more about what is likely to just cause discomfort. I hope that Dr. Murray’s article will be widely read by both the physicians who make recommendations for patients at the end of life and the non-physician public who make decisions about what they want for themselves and their loved ones.

A version of Dr. Murray’s piece later appeared in the Wall St. Journal on February 25, 2012 with the headline “Why Doctors Die Differently”. It is discussed by Dr. Kenny Lin in his blog, Common Sense Family Doctor, Addressing gaps in end-of-life planning”, March 15, 2012. Dr. Lin focuses on the important issue of “advance directives”, which includes Living Wills and Durable Powers of Attorney for Health Care (DPOAs), mechanisms through which people can help to ensure that their wishes for how they want to be treated – or not treated – at the end of their lives are honored, even when they themselves are not able to make specific decisions. A DPOA designates one person – one with whom, hopefully, you have had serious discussions about what you really want – to be your decision maker. This is very important; while under the law spouses have the right to make decisions, when there is no spouse and are multiple adult children there is no provision for who decides other than DPOA. There is no provision for a majority vote. While it is always best if everyone in the family agrees on a course of action, it doesn’t always happen. There may be several children in agreement, and one who wants something different. Sometimes this ends up in court, with a judge deciding. This is not the best scenario, which is why there should always be a DPOA. It does not solve every problem, but it definitely helps to have a specified decision maker. This issue is also addressed, from a patient and family perspective, in a recent NY Times Op-Ed by Sylvia Jacoby, Taking responsibility for death (March 31, 2012).

Such planning, however, requires thinking about hard issues. You have to decide if you want to have cardiac resuscitation if your heart stops, or be placed on a ventilator (breathing machine) when you can’t breathe on your own, or be “fed” through your vein when you can’t eat. These are all legitimate medical interventions that can have real value when there is an acute problem that is likely to be reversed (someone is temporarily unable to eat or swallow, or breathe on their own, but are likely to be able to in time). Cardiac resuscitation, which involves electric shocks and chest compressions, contrary to what you see on TV shows, hardly ever “works” when applied to people at the end of life whose body is in the process of dying, if by “work” one means a reasonable period of survival. It sometimes gets the heart re-started, but most of the time it happens again. A small percent of people who receive this treatment leave the hospital, and very few are back to “normal”. It is great to do for healthy younger people who have an episode of trauma (like on TV) but is unlikely to have benefit for folks at the end of life.

So why do we do it? Not only cardiac resuscitation, but so many other interventions that are of little or no benefit, especially when the body is suffering from the failure of multiple organ systems. And when, as indicated by Murray and Lin and many others, it is not what doctors want for themselves? As usual there are many reasons. Part of it is that doctors are, by and large, trained to do “whatever can be done” if there is “a chance”. However, a chance of what? This is a big question. To stay “alive” but unaware of one’s surroundings (from dementia, coma, or both), on a ventilator, and often in pain, for a few days, hours or minutes?  Even when doctors think about this issue, they often worry that if they don’t do something, they may be criticized, or even sued, by the patient’s family; they tend to go with the idea that doing something is always safer (from this point of view) than doing nothing.

The whole field of palliative care exists to help people and their families get through the inevitable process of dying with dignity, but there are far too few palliative physicians relative to the number of doctors trained to “do something”. Years ago, a co-worker’s elderly mother was dying in the intensive care unit (ICU). I went to visit. The woman was very far gone and unable to understand anything; the family, several adult children, was being asked to give permission for a fairly invasive procedure. They had been told it might “help”, and asked me what I thought. I was pretty sure it wouldn’t, but first checked with the doctor to see how he thought it would. I then spoke with the family and asked what “it might help” meant to them. They said that they hoped that it would make her “better”. I asked if this meant that she might become conscious, alert, maybe be able to talk with them, maybe be able to say goodbye one last time before she died? Yes, that is what they meant. I gently explained that this procedure might help correct some laboratory values, but that there was no way it was going to make her “better” in the way they hoped, although there was a good chance that she would still experience the pain associated with doing it. They opted not to have it.

Why didn’t the doctor make this clear to them? Perhaps it was because he was young, and wanted experience doing the procedure, and really thought that making lab tests better was “helping”. (There is an old joke that at Harvard students and residents were always pressured to make sure their patients had normal laboratory tests; the patient might die, but it was critical that they did so with their electrolytes in “perfect Harvard balance”.) Perhaps he had been trained to always “do something”. Perhaps he saw this large, hovering family and was concerned that they would be upset, might sue, if he didn’t.

Or perhaps he didn’t know how to talk to them. Is there a social justice issue here? After all, death comes to everyone, and as Dr. Lin points out, advance directives are important for all people to have, not just members of communities that have suffered health disparities. But often the social class or ethnic difference between doctors and patients makes communication more problematic, makes it harder for doctors to know how to best address what are already difficult issues, makes patients’ families suspicious of whether a treatment being offered is “research” being done on someone because they are poor or minority, or, alternatively, whether a treatment is not being offered for the same reasons.

I have cared for many people who were dying but whose families wanted more done. People who already had advanced dementia and whose physical bodies were falling apart. People whose heart and kidneys and lungs were failing, who couldn’t swallow and might choke on even a small amount of food, but whose families believed that if we didn’t do a surgical procedure to poke a hole directly into their stomach we would be starving them; who thought that if we didn’t plan to do cardiac resuscitation or given antibiotics for a possible pneumonia, that we would be killing them. Sometimes I am able to point out that death happens to everyone, and that having your heart just stop, or having pneumonia, or not being fed, are relatively easy painless and natural ways to die. Sometimes I am believed and sometimes not.

While there are, of course, times when a family member is truly “crazy”, paranoid or delusional, a more common issue is that they are just acting out their guilt. The stereotype (because it often happens) is the “son from California”, who flies in at the end of life, has usually not been involved in the care of his parent for years while a sibling (usually a sister) was doing all the work, and who now wants “everything done”. (A really good reason for one person to be designated DPOA.) But sometimes there is simply a trust issue, not being sure that the doctor, especially one from a different class, race or ethnic background, is really treating their parent with the respect that they deserve, with the respect they would give to one of their own family members.

Perhaps if more people understood what Dr. Murray is saying about what it is doctors really want for themselves and their families, or if their doctors took the time and energy and effort to explain it to them, folks would be more able to believe and accept it when the best course is not to do any more.

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