Tuesday, January 17, 2012
Doctors' choices at the end of life, for themselves and their patients
"Soon I will rest, yes, forever sleep. Earned it I have."
--Jedi Master Yoda
I have some bad news for you. You're going to die.
Not soon, I hope. But for the foreseeable future the death rate will remain one per person.
This week a patient pointed me to a wonderful article by Ken Murray, "How Doctors Die". Dr. Murray, a USC Family Medicine physician, argues that doctors faced with terminal illnesses very frequently forego aggressive care and die peacefully at home, while other patients are subjected to invasive, painful, and futile care at the end of life. I urge you to read the article. In fact, you might want to read it first and then return to this post.
All doctors have seen cases of patients receiving invasive, aggressive, futile care. Some cases involve not just care that is unlikely to help, but care that has been shown in studies not to help, like feeding tubes placed in patients with dementia, or CPR performed on patients dying of cancer. This is a calamity because it subjects patients who are frequently frail and in the final days of their lives to gratuitous suffering without any potential benefit. Worse, as if the suffering of the patients' disease was not bad enough, the suffering due to futile care is inflicted by physicians.
Though Dr. Murray also highlights the astronomical cost of futile care, I think the economic argument is unnecessary and counterproductive. These cases are a calamity even if the care was free. Patients should understand that we are appalled at such outcomes because of the harm done to patients, not because of the wasted resources.
Dr. Murray describes the problem well and recommends the path frequently chosen by physicians when they themselves are ill, hospice care, a focus on quality of life, and death at home. But how do we convince patients that this is best? Many patients believe that medical technology is omnipotent, and that recommendations for hospice care amount to giving up. Other patients, bewildered by the complexity of healthcare delivery, suspect that doctors have a financial motive to withhold lifesaving care. These misunderstandings can only be reversed if there is trust between patient and doctor.
Doctors, of course, share much of the blame. Ordering another test, recommending another procedure, and prescribing another medicine are all easier than giving a patient and her family terrible news. Maintaining a false hope is easier than explaining that this illness will be the last.
The best patients can do is to tell loved ones their wishes in advance, and develop a long-term relationship with a doctor they trust.
The best doctors can do is be honest when things are dire, and recommend against futile care with patience and compassion.
"May you die well."
--Klingon benediction
Learn more:
How Doctors Die (Zócalo Public Square)
My previous posts about end-of-life care:
When Less Care is More
A Dose of Realism about Advanced Dementia
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.
Labels: Albert Fuchs, end of life, guest post, palliative care
posted by Albert Fuchs, MD at
9:00 AM
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Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:
Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Medical Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Other blogs of note:
American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
PLoS Blog
The Public Library of Science's open access materials include a blog.
White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.
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