Ken Murray, an MD and Clinical Assistant Professor of Family Medicine at USC, informs us that non-physicians do not die like physicians. To make things better, however, we should consider doing so:
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.It’s not a frequent topic of discussion, but doctors die, too. 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.
Murray gives us no data to support not only this claim, but also why physicians might choose to die this way:
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.
But let us grant him these facts, despite the lack of data, for the sake of argument. And then let’s us get beyond the scary images here and focus on the social situation in which physicians find themselves. Murray himself notes that administering “medical care that makes people suffer is anguishing”, and so we need to ask questions about what a career of such anguish might do to one’s ability to be rational about end of life choices. Furthermore, when deciding about what kind of life is worth living, there are at least three reasons to be skeptical of the answer that many physicians give. First, while they are often highly skilled organic plumbers, they almost always have no particular expertise in the complicated ethical questions surrounding quality of life issues. Second, as I pointed out in my last two posts, they are often wrong about the diagnosis and medical facts on important end of life issues. Third, they almost always lead very privileged, educated lives such that they are disproportionately unlikely to understand or imagine how those without such benefits can find their lives fulfilling.
Indeed, a recent study found that patients actually preferred longer life to quality of life. “I was quite surprised by the results,” said lead author Dr. Hans-Peter Brunner-La Rocca, of University Hospital Basel in Switzerland. “Often we think we know what is best for a patient, but this is often wrong.”
Former director of Medicaid and Medicare services Dr. Peter Bach helpfully nuanced Murray’s position:
The more nuanced reality is that some aggressive treatment delivers value and is appropriate, even though some patients who receive such care die; other treatment is too aggressive and should be curtailed no matter what the short-term outcome. No one knows how many patients are more like my patient, who could have died but whose life was saved, and how many undergo treatments and tests even though there is no meaningful chance they will benefit from them. The important thing is that it’s not all of one and it’s not all of the other. Today the medical profession lacks a shared understanding of which patients are which. That gap must be addressed. It will be an excruciating task, and it will be politically noxious. Someone will again accuse officials of forming death panels. But leaving the distinctions to individual doctors leads to inequities, harm to patients, distrust in medical care and lawsuits; ignoring the problem should not be an option, either.
Indeed. But in the meantime there are lots of other things we can do to drive down the costs of health care. We can provide primary care for our most vulnerable populations, we can make a concerted effort to cut waste and fraud, and we can make efforts to treat more people at home.
One thing we need not do, however, is die like a physician…or at least as Dr. Murray would have us die.