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Let’s start a new, rational discussion about end-of-life care

Sarah Palin’s 2009 false “death panel” charges made any reasonable public discussion about end-of-life medical care almost impossible.

Maybe, just maybe, we’re ready to leave fear-mongering behind and return to a rational conversation about this topic, which is so heartbreakingly important to every family.

Dr. Ken Murray
Dr. Ken Murray

To enhance that conversation, I suggest an insightful and moving essay posted recently on the Zocalo Public Square website, a project of the nonpartisan Center for Social Cohesion. Written by Dr. Ken Murray, a clinical assistant professor of family medicine at the University of Southern California, it begins with his observation that doctors don’t die like the rest of us — and not for the reasons you may think.

Writes Murray:

What’s unusual about [doctors] 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. …
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.

“How has it come to this — that doctors administer so much care that they wouldn’t want for themselves?” Murray asks. To begin with, he says, people tend to have highly unrealistic expectations about what current medicine can accomplish, and doctors often lack the time (or communication skills) to explain what is realistic. Doctors also fear litigation, so some will do whatever they’re asked, even if they know a treatment is futile and will prolong the patient’s suffering. And “in some unfortunate cases,” acknowledges Murray, “doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money.”

Then there is the medical system itself, which can sweep a terminally ill patient into a world of CPR attempts and life-support machines, even when such excessive treatments will not improve the patient’s outcome and may severely impair his or her quality of life. (“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,” says Murray.)

“It’s no wonder many doctors err on the side of overtreatment,” Murray writes.

But not when it is they themselves who are terminally ill, Murray insists. “Doctors still don’t over-treat themselves,” he writes. “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.”

Murray doesn’t offer any statistics to back up his assertion that physicians are less likely to overtreat themselves at the end of their lives, so I’m not sure if that statement is true. Still, his essay provides an interesting and helpful perspective on end-of-life care. It’s time to stop the fear-mongering and re-start the conversation.

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Comments (5)

  1. Submitted by Paul Brandon on 12/15/2011 - 11:27 am.

    Two answers:
    Economic benefit (fee for service).
    Avoidance of economic risk (economic and criminal liability).
    These are the costs of our ‘free enterprise’ medical system.

  2. Submitted by Thomas Swift on 12/15/2011 - 02:17 pm.

    As long as our medical system remains private, decisions and discussions regarding life and death will too.

    But I don’t mean to discourage supporters of socialized medicine from enjoying a rousing death panel debate.

  3. Submitted by Thomas Swift on 12/15/2011 - 03:11 pm.

    Paul, the avoidance of economic and criminal liability is the costs imposed by a free market legal system.

    If there is one sector of the economy that conservatives would love to see taken over by the government, it’s law.

  4. Submitted by Rachel Kahler on 12/16/2011 - 09:46 am.

    The legal system is the last one that should be taken over by the government. The legal system was designed to protect the people from undue punishment…and the government.

    In ANY healthcare model, we must be rational about end of life care. While each individual should make their private decision, our standard procedure when doctors don’t have that private decision in front of them, should not be to prolong suffering. Providing hope where hope is appropriate is one thing, but we Americans have unreasonable expectations from medicine, in part because it’s part of our culture to reject consensus, but also in part because we cling to those few examples of someone “beating the odds.” At what cost to the patient and family? Pain, suffering, bankruptcy…for a few more months, MAYBE.

    We have new drugs that will add days to your life if you suffer from certain terminal diseases. And people complain that the cost of those new drugs is excessive and drug companies are greedy and..and..and… The benefit is DAYS, people, and only on average. If you can afford to buy those days (hoping to be above average), fine. But if you can’t, you shouldn’t expect such a little benefit for nothing…we all pay for it in so many ways. Either way, ask yourself, is this what I really want? Is this additional time that I add to my life, or is this additional time that I merely add to my existence?

    That is not to say that we shouldn’t continue looking for cures to the most deadly diseases. We should. After all, even incremental steps add up. But we should recognize that medicine is, ironically, not a cure all. We will all die of something, the question is whether we will do it with dignity, fighting reasonably for a good life, or we will do it in denial, fighting tooth and nail to get every morsel of existence.

    Until we can discuss our deaths with our families AND our doctors BEFORE death knocks on our doors, end of life care will continue to increase the cost of medicine overall. What is wrong with encouraging people to have that private conversation with their doctors as well as their families?

  5. Submitted by Ray Schoch on 12/16/2011 - 10:05 am.

    Good piece, Susan…

    While Mr. Swift babbles about the benefits of the “free market,” it’s more than a little interesting to note that most physicians don’t choose for themselves the sorts of treatments routinely performed on other terminally-ill patients. I’d like to see some numbers to support the anecdotal evidence, too, but I have a sister who’s an ER physician, and her “war stories” are very much in line with Ken Murray’s conclusions.

    This is a conversation my Mom had with another of my sisters who’s a lawyer, and the necessary power-of-attorney and other documents, especially the “do not resuscitate” one, were prepared well in advance. The will to live is perhaps our most powerful drive, so it wouldn’t be entirely accurate to say that my Mom died “peacefully” at home – heart failure doesn’t really allow for “peace” or “dignity” so much – but she did, at least, die in her own bed, with loved ones at hand, and without bankrupting the family in the process.

    If I can depart under similar circumstances, it will be a good thing. We should all hope to avoid what former Colorado Governor Dick Lamm calls “…the $100,000 funeral,” and Murray confirms this.

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