Blog | Monday, August 31, 2015

Talking about death


A few recent experiences have me thinking about death.

The first was hearing a story on the radio about how physicians “manage” their deaths. The gist of it was that physicians are more likely to die at home without aggressive life-extending interventions than the general public. The implication was that more people would have a “better” death, more in accord with their own wishes, if frank discussions about end of life care were more common.

I didn't think too much about the story, which registered only a “no kidding” in my mind when I heard it, until I thought about it in the context of two deaths that touched me this past week.

The first was a medical school classmate of mine who died after a long course with prostate cancer. A message from a mutual friend who shared the news of his passing concluded with this: “at least it all developed as he and [his wife] chose, at home, with peace.” It conjured up a scene of serenity, and I was oddly glad that I was able to imagine him, comfortable and surrounded by his family, gently slipping away.

That scene was nothing like what was described to me as the final days of a friend's elderly father, who died in a hospital with advanced heart failure. He had had a long history of heart disease. Over several months, he was hospitalized half a dozen times for worsening heart failure. He spent his final days, I learned, “in agony,” uncomfortable, thirsty, and short of breath. Sounded absolutely horrible. And here's the thing that really got me: She was surprised that he died.

Really? How could she be surprised? To the cardiologist in me, it was clear that he had been in steep decline for months. The prognosis for an elderly man with progressive heart failure leading to multiple hospitalizations is obviously grim. Maybe this was just the subconscious denial of a loving daughter, who could not imagine losing her father. I am sure that played a role.

But there was more. She told me that she was surprised, in part, because she was so engaged with his doctors over the details of his care that she “lost the forest for the trees” and did not see the bigger, inevitable picture. Also understandable. It is easier for many to fight the day to day battles than to think about the bigger questions of “why” and “where is this going” or “how is this going to end.” I don't blame her.

But I can't help but think that his doctors failed him, and her. Maybe his doctors tried to engage them, and maybe they didn't want to hear what was being said, but over months and multiple hospitalizations, it seems that there was no effective conversation about these bigger questions. No chance, apparently, for her and her father to have it end “as he chose.” Instead, he was miserable and she was shocked.

So sad; so unnecessary.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.