Hippocrates, the father of medicine, famous for a quote frequently attributed to him: “first, do no harm” (Photo credit: Wikipedia)
How will you face death?
Ken Murray, clinical assistant professor of family medicine at the Keck School of Medicine at the University of Southern California recently wrote a thought-provoking essay, How Doctors Die, comparing how doctors approach end-of-life decisions to how an average layman does.
It’s a lovely piece; I strongly urge you to take five minutes and read it.
My favourite excerpts:
What’s unusual about [doctors] is not how much treatment they get… 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. And they know enough about death to know what all people fear most: dying in pain, and dying alone…
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.
Modern medicine is a marvellous thing. It is excellent at reducing the risk of illness or preventing further deterioration. But it is not good at managing death. Murray accurately describes how an unwitting constellation of medical, patient and systemic factors frequently work to prolong terminal misery. He is speaking of medical practice in the USA, but it is certainly true in the UK as well, and I suspect true for whatever country you practice in.
It is in the nature of humanity to fear death; we tend to avoid thinking deeply about such things. Much of the existential suffering that humanity experiences is related to the reality of mortality. As a psychiatrist, I see its distant shadow looming behind many of the apparently unrelated fears and anxieties of patients. Mortality sets a countdown on life, restricting freedom and choice.
Healthcare professionals gain a familiarity with death that the average person lacks; we know what a good death is, and what a bad one means. This influences our own choices. The challenge is how to pass this wisdom on without coming across as uncaring. Being open about the realities of death with others, especially our patients, can be challenging to them.
Murray’s essay is an excellent start.
Thank you for confirming what I always thought: now I am sure that if I found I had a certain condition, I would refuse treatment rather than go through (any more) surgery or longterm drug treatment.
I think it depends on the condition, one’s preceding level of health and having a really open & honest discussion about the odds of success and potential side-effects and complications. Sometimes treatment can really help. Other times, it’s a more finely-balanced decision. And occasionally, it does little more than prolong suffering. Doctors have a level of knowledge and experience that makes decision-making around their own care a bit more straightforward than the average layperson might find. Doctors can also a bit more realistic about the limits of medical science… although not always, it has to be said!
Excellent essay. I have bookmarked it and will be sharing it with the person mostly likely to someday make end-of-life decisions for me.
I should have specified… if I am unable to make them myself.
Remember also that medical science constantly advances, so what is true today may not always hold in the future. This is actually a big part of why doctors have an advantage in choosing their end of life decisions; even if they don’t keep up to date with the science themselves, they can quickly get back up to speed if they’re faced with a terminal illness and then choose realistically between options.
So I would always advise people to have really open & honest discussions with their physicians about the risks and benefits.
I have given this subject much thought, and my educational ambitions lie somewhere between counseling psychology and medical ethics. Most everyone I talk with has a story in which a caring, trustworthy, and system-savvy person could have offered their help in improving a dramatic medical situation. It seems that doctors are limited in their ability and desire to offer potentially time-consuming counsel, especially with the risk of litigation looming, as well as the difficulty of establishing on-the-fly trust which you have mentioned. Do you have any thoughts and/or experience regarding a professional acting as an intermediary between doctor/hospital and patient/family?
Thank you- I appreciate your work!
Thanks Ben.
That’s a good question. I think all doctors want their patients to have as much information as possible. The trouble is not in the information, but the _interpretation_ of the information. This is where simply explaining facts/odds/chances becomes insufficient to truly inform a person about the emotional & practicalities realities of death and medical interventions.
Doctors have a tricky path to tread when interpreting information for patients; the risk is that they put in too much of their own opinion/feelings rather than letting patients decide. What patients really need in these circumstances is a “wise adviser” (whether Dr, friend, or counsellor) who they can trust, but medicine has moved away from this approach (it was too paternalistic at times) and towards a very firm informed consent model (where the onus is on the patient to choose).
Really, the best thing would be for society to have an open discussion about all these issues so people are pre-prepared for it, but death is so frightening a concept that it finds that difficult. Instead it has to be done at times of emotional distress, which automatically diminishes decision-making quality.
I would suggest that any advocate or counsellor in this situation should try to ensure doctor, patient and family all sit down together and talk openly about the realities. Communication & a feeling of being able to be honest is the key. If the doctor isn’t a good communicator, the advocate has a role in helping communication flow more freely. In a way, a good advocate becomes the equivalent of a faithful wise family retainer, smoothing and guiding their path, nudging lightly if needed but never telling someone what to do.
Hope that helps!
Reblogged this on SomethingPesh.
This so well phrased, had similar thoughts but thanks a lot for phrasing this so well and helping with difficult decisions.