by Ken Murray
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. 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. 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.
To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.
How has it come to this—that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.
To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.
The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. 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. Poor knowledge and misguided expectations lead to a lot of bad decisions.
But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.
Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.
Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.
It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.
Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.
Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.
But doctors still don’t over-treat themselves. 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. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.
Several years ago, my older cousin Torch (born at home by the light of a flashlight—or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.
We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.
Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.
Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC.
*Photo courtesy of patrick.ward04.
I read about your article in a piece written by Joshua Rothman in the 1/15/12 Boston Globe. Kudos to you Dr. Murray for bring this topic to the forefront. My wife is a physician and we’ve spoken at length on end-of-life choices given her professional experiences and my own personal experiences with death and dying. I will link your article to my blog (www.eol2die4.com) because I want readers to have access to quality articles on issues surrounding death and dying. I hope you and your readers take a minute to check out my blog, I think I use a unique format to raise the level of awareness around this critical time of our lives. Thanks again.
Thank you so much for sharing this beautiful and moving piece. I hope you do not mind if I feature this post in my blog and backlink to this site. I just lost a dear friend a few weeks ago and this topic is close to my heart. God bless you for all you are doing.
As a retired Orthopedist I agree with all that you have said. You have said it well and it needs wide distribution.
Thank You
David Wiebe,M.D.
As a strong proponent of the death with dignity movement for many years, I have been encouraged by several efforts recently to bring this issue to broader public awareness, including your article. My father was 90 when he died last year and I was his health care proxy. He asked me years ago to take that role and honor his living will which I gladly did. My husband and I (in our fifties) have had living wills for years. Having seen how bad hospitals can be in “caring” for terminal, elderly patients, I have no intention of being in that situation myself either. My mother had hospice for a few days (should have been much longer) and died at home ten years ago. I am a big fan of hospice. Thanks so much for your reasoned, insightful piece.
I saw a 60 minutes show covering this and how doctors many time say we need to think about the quality of life. I think the special was on Medicare and how we could cut back on expenses when we know a loved one will be on assisted care in the hospital and in pain for an extended time period with little to no hope of getting out.
I’m still haunted by my fathers last days and death in the ICU in Wellington, NZ.
He was hooked up, horrified and helpless, one of the most independent people one could know. Not the wisest at all times perhaps, but he was terrified to find himself in such a dependent state. The shock helped his demise.
My instincts were to free him vehemently and immediately from the tubes and machines and sling him over my shoulder, walk up to the top of the nearest hill for him to die breathing in fresh air and sunshine.
So what is the best way to ensure your wishes are honored? Living will, “no code” medallion, advanced health care directive, ???
How does one go about drafting, certifying, and recording their wishes?
Sir, I commend you on your article. I am one of those doctors treating patients at the end of their life. As an intensivist in one of the largest hospitals in northwestern Europe I am confronted on a daily basis with people struggling for life in a critically ill condition. My colleagues and I work in a country that has made the topic of end-of-life decisions out in the open possible. We are one of the few countries where assisted suicide-on-demand is possible under justifiable very strict conditions. You must know that we experience the pressure of patients, their family and patient organizations and are forced against our will to comply with wishes without a rational therapeutic impact on treatment, but when threatened verbal and sometimes physical you think about your own family as well. The world is changing, internet has been good for exchange of information but also of ideas and views. Not always to the direct benefit of individual patients, but it has made doctors think about their actions as well and that is a good thing. May patients, their families and organizations also learn from all this abundance of facts and figures how hard they can make it for doctors to remain rational and professional and that their primary goal is to protect the interests of the patient. This may include withholding treatment if and when this has become futile.
I recall hearing about the death of Richard Feynman, the physicist, who died of cancer at 58. He was lying in bed breathing in and out and said, “I’m glad I only have to die once. It’s so boring.”
All I know is I don’t want to die without my faculties, and I don’t want to die bored out of my mind. A little pain I can cope with, and they have great drugs for the serious pain. I just want to go with a book in my lap, or at my piano, or with yarn and a crochet hook in my hand, or something. Making something, or doing something. I don’t want to go after six weeks, six days, or six hours of listening to some stupid bleepy effing thing bleep for the seven millionth time. Death is fine, BOREDOM is not.
thank you. it makes me think of ivan illich’s critique of the “iatrogenic damage” to people often done by a medical industrial complex that works beyond a human-scale in the name of progress. it was a refreshing reminder that if the system can be damaging and dehumanizing, it is not lost on those most familiar with it.
Short of euthanasia,this seems to be the most reasonable approach when faces with such drastic situations.This choice is least agonising,minimally invasive and meagerly taxing.
At 66,I think I have couple of more decades befor I go to the eternal sleep,it seems I have made my choice on quality of death I wish to have.
Better to write in your own obituary-” Here goes a man who lived life on his own terms.”
interesting conversation, particularly from a medical doctor. in our community we do not talk about death and dying. this is something that we all will do, it is a part of life, as much as the sun comes up, and goes down, so will we all die.I work as a palliative care nurse in the community and in hospital, working with the pt and friends and families. My greatest challenge is talking about dying, pts fears, their concerns and things they want to do before they die. Good on doc for embracing his cousin, supporting him and enabling him to live before he died.
Thank you for this article. My father died in 2001 after suffering a second stroke after a few days in a public hospital. In the country where we live, private healthcare is widely thought to be superior which public hospitals are shuuned by almost everyone who can (or want to show that they can) afford private healthcare. But I’ve always had high regard for govt run hospitals and see/ hear daily instances of things going awfully wrong in private hospitals and the patient is packed up to a govt run hospital. My 3 kids were all born in govt run hospital (the “national” hospital where I the local royalty habe a special ward dedicated to their family – surely then the hospital can be good enuff for mere mortals like us?). In fact, my siblings and I were all born in govt hospitals (me in exactly the same hospital as my 3 kids!). My eldest came with a C section (last minute featel distress due to the cord around her neck) while the later 2 kids came out beautifully and naturally. But some frens did frown upon learning that my kids were delivered in a govt hospital (with the best medical facilities in the whole country) and not a private birthing centre with a bunch of untrained “nurses” and an ambulance waiting for the wrong moment! (BTW, I’m not a doctor but have designed some major tertiary care and specialist health facilities on two continents).
So back to my father’s story. Well he was there a few days. And then one night, he died holding my hand. My mum was there beside him and so was my brother. His two daughters were overseasa and could not be there to see the last moments of their father’s life on earth. I remember calling my ez who was overseas and crying over the phone with her as we were still friends then. Telling her that Dad was going. There was nothing much she cud do except console my sobbing. And d my Dad left us.
Just a day to two earlier I remember the doctor telling me that my Dad was responding and there was not much else he / they cud do. He was quite a young doctor (only 29 I remember noting on the death cert he signed later). I think he too was trying to tell me to take Dad out of the govt hospital and into a private hospital for some “better” treatment. Some friends and relatives too – without quite saying the words – implied that perhaphs we shud have taken Dad to a better place. I remember talking to my Mum soon afterwards asking her if I as the eldest son had made the right decision of taking Dad to the govt hospital. Her reply was that nothing cud have changed God’s plans.
To this day the event often crops up in my mind and I’m not sure if it was the right decision I made. Could I habe prolonged Dad’s stay here a bit longer? But maybe he may have been worse off. After his first stroke, he had become extremely weak in his legs and had to be assisted. My Mum took great care of him for years.
The gremlins in my head will still haunt me to my last days but after reading this article, atleast I’m better prepared to fight them the next time they appear or for my own day. Great job, Dr.
I found myself as sole medical power of attorney with my dying paternal grandmother in 2002. Meeting with the doctors after a 17hr drive from LA to Denver CO, I found out that she had a broken hip [femur/socket], and she had slipped into unconsciousness.
The doctors were good, but guarded. I asked them “Do you know she has a morphine allergy?”. No, this wasn’t known. Finally, with considerable difficulty, I told the doctors the following: “She’s comatose, 89 yrs old, bed-ridden, and will never walk again. I say no hip-replacement. This is it”.
They all looked at each other, and I could tell behind their expressions they were ecstatic that they didn’t have to perform an expensive, meaningless, painful operation. If they could’ve high-fived each other, they would’ve. And I don’t blame them at all.
She died twelve hours later, and was released from this mortal coil.
After reading this fantastic article my wife and I decided to dedicate it to the memory of our daughter Zoe who died of cancer four years ago.
She was a wonderful young woman who had the courage to say no to chemo and in doing so she lived almost nine years with ovarian cancer. Her doctor said this was, “unheard of at her age”. She was 32 when she passed away and for eight plus years she lived as a healthy person who lived her life to the fullest. Thank you Ken Murray for having the courage to write this article and we will share it with as many people as we can.
In 1969 when I was an intern I asked a staff man at the University Hospital “where are the doctors?” and he glanced up and down the hall as though looking for some, then “Hmm… come to think of it.. I trained at Sloan-Kettering, we didn’t have them there either.” Since then I have seen none in hospitals and none in the many nursing homes I’ve visited. We choose to avoid the proverbial Last Six Months (Is that half our health-care bill, the way?) and prefer to die at home with dignity, or provide the support for a colleague to discontinue support. Some die of course in a hospice, on a morphine-ativan drip, man, what a way to go! I am in complete agreement with the above. Death is a time for dignity, peace, love of family.
To David B. You may find answers to your questions on my blog (eol2die4.com) and selecting Five Wishes link under Sites on the right hand side of the blog.
Thank yo so much for writing and posting this article. i have sent it to my friends, most of whom are not medically trained, for their education. When my great aunt and Godmother, whom i loved dearly, was dying of cancer, we kept her at home. A week or so before she died, i asked her if she wanted to go to the hospital or stay with us where we would keep her as comfortable as possible. She looked me in the eye and said she wanted to stay in my mom’s home. She died peacefully, without machine, lines or pain. Sometime later, my mother expressed concern that maybe we should have done more to prolong her life. I pointed out that taking her to the hospital would have prolonged her death not her life. i know that we did the right thing – she was 88, had stage 4 cancer and crippling arthitis and severe pulmonary hypertension. It was also her expressed wish (She also had an advanced directive and a DNR). Even so, my mom had second thoughts. it is a painful, confusing and overwhelming time for families and the doctor patient relationship, which is disappearing in modern medicine, is most important at these times. I hope that your article saves some people the agony of the terminal ICU experience. Thank you again
In my 22 year career as a general surgeon, I have been fortunate to use every aspect of my training from general surgery to trauma to vascular surgery to prolong the quality and quantity of my patients lives often in the most dramatic fashion. Saving someone with a ruptured AAA, a bleeding spleen or a perforated diverticulitis provides surgeons with the immediate gratification that they sought when they made their choice of specialty. However, even in the earliest years of my career, some of my most thankful patients and their families were ones that I didn’t operate upon. It certainly was sometimes more difficult for me to take a moment, explain to the patient and their loved ones that they have unfortunately reached the final stage of their life and now I had to assist them in deciding how this final act would play out. Sometimes this discussion would be in a moment of extreme urgency in the ER or ICU or sometimes with more time at the bedside or in the office. Inevitably I would tell them the facts and statistics as I not only knew them but also how I personally felt about their situation. When asked if it were my parent, sibling, spouse, offspring in the bed would I be making the same recommendations, I inevitably would tell them “yes.” This especially applied if I personally was the one contemplating my last moments since inevitably that time will certainly come. Life is a 100% fatal condition. Recognizing when it’s terminus has arrived and helping each other take that final step is as important a role for a physician as applying their knowledge and skills to prolong and improve life. If as physicians we wish such a more dignified, peaceful ending to our lives we must set aside our fears and any other ulterior motives and provide that for our patients as well.
Thank you for writing this article. As physicians, I think a lot of us get trained with the idea that we are fighting off illness and death for an inevitable amount of time. Medicine these days seems to teach a formula for care. that involves a lot of tests and interventions. And so often these days there is less questioning about whether every test and intervention is right for the patient sitting in front of us. The system now a days for the sake of standardizing and mitigating litigation teaches a lot of us to follow formulas which in some ways is good, but I find that less and less physicians take the time to see what is right for the patient in front of them. And when I mean right, I mean a plan that the patient fully chooses.
I think like anything in life, our actions are most effective when we set a strong intention. Then what are our intentions when we care for our patients? This is the important thing to constantly check. After residency, i truly realized my intention is not simply to delay death and illness, but to try to encourage my patients to live better and happier lives in whatever capacity is right for them. That means understanding that I may have a 25yo diabetic that refuses to take their insulin regularly and get their HgbA1c less than 7%, but creating a safe space to remind them of the risks, encourage them, and meet them where they are willing to meet me is whats important. So that when they get scared enough to prioritize their health issues, I am here and willing to work with their choices. Death and dying are no different. We have a lot of information available to us, but what is our responsibility? I think we have a responsibility to help our patients to live better lives and to die better, becuase inevitably we all are dying.
I find that the issue at hand is that so often, we as physicians know long before patients do that things are heading for the worst. We start to get that feeling in our gut that even though the tests aren’t final, this patient is seriously ill and things are going bad. We even have a picture of what the next few months of this patients life is going to be like, in and out of the hospitals and filled with a lot tests and frustrations, yet we remain silent. We delay communicating this information, until all the tests are back and then we hide behind a lot of technical information when communicating a dire illness. This is what I think the issue is. If our intention is to help our patients live better lives that means we have a responsibility to communicate these ideas early on compassionately, skillfully, and like always help them to make the choices that are best for them. These are discussions that should start as early as possible when patients feel well and can have time to understand and decide what matters to them. Death and illness are not the enemies, they never have been.
A life selfishly lived, lonliness, suffering without wisdom these are the enemies that all of us fight till the day we die. This is the fight that we as physicians have the intimate privilege of being a part of, when we care for our patients. Death and dying are a natural part of all our journeys, as physicians who care for patients and their families, our intentions shouldn’t simply be to fight off death and illness, but to help them understand and travel this journey in the way that they choose. That means as the keepers of information, our responsibility lays in helping them to understand things as early as possible and then decide.
Death and suffering are the hardest conversations and situations to witness, let alone participate in or initiate, but this is our privilege and responsibility. If each of us try to ask why having as much knowledge as all of us do about death and dying, leads us to make the choices we do for ourselves, then the next part is to revisit what is our responsibility to our patients. This is not to say that our choice for ourselves is the right choice for everybody, but we have the good fortune of understnading death and suffering and that allows us to make compassionate choices for ourselves and our family. Then our duty is to offer our patients this knowledge and compassion as soon as we can, and then walk the journey with them in making the choices that are right for themselves. The purpose to life is not to evade death, but to live well until we die, as physicians we have such a beautiful and blessed privilege to be a part of so many patients’ journeys, all of us must learn to walk the full length with compassion and humility, and in so doing we learn so much at the hands of patients and thier families!
Two quick points one is the best question you can ask a doctor is “what would you do if it was your mother?” Another is it is often better going to an academic center where the doctors are not being paid on a fee for service basis but are largely salaried.
A longer point is that Americans are fixated on individual liberties and their right to choose without regards to the greater community. When I was a medical intern there was an 80 yr old woman who was talked into open heart surgery by her daughter, it did not go well. She was left with in a vegetative state on life support in the ICU. To make matters much worse she developed a severe pseudomonal infection in her mediastinum that was resistant to all the normally tested antibiotics. He daughter was so racked by guilt she refused to “pull to the plug” and she was literally putting everyone in the hospital at risk by refusing to allow her mother to move on. BUT we had to respect her wishes misguided as they were.
A superb article on how doctors choose to die. Def echos my sentiments . I think most of USA docs would agree. I would be curious how docs in India and uk and Australia think. Also how different is the common mans opinion … I def want DNR tattooed on my chest and use hospice to die with dignity and comfort but most importantly without fear. I think some may understand that if is not the fear of death that is there but the fear of dying alone , helpless to make decisions if incapacitated ….
I’ve worked as a clinician and pathologist:
1. The seriously ill elderly end up in ICU with all the tubes because the family, perhaps through guilt, want “everything” done for grandmother. Why shouldn’t they?? They aren’t paying for it.
2. The one thing you cannot find on the internet are the Meier-Kaplan survival charts for each chemo therapy approved by the FDA. Each chemo agent must have a Meier-Kaplan survival chart presented to the FDA prior to any approval. Even the NCCN, doesn’t provide survival charts. These results are terribly poor.
3. When I was diagnosed with high grade, high stage(T3b)prostate cancer, i knew the current chemo had no legitimate studies to support it. I went to alternative medicine and used the Solomon Wickey protocol and have survived 6 yrs in excellent health. My hair is falling out, but that’s due to old age.
4. Chemo will kill you. Oncologist try to get 2 rounds of chemo in you before the chemo kills you. Years ago, before chemo, I autopsied patients who had survived cancer for 10 years. Their bodies were shot through with small BB sized tumors, the metabolic burden of which ultimately killed them.
5. Alternative medicine offers many protocols for treating cancer. It would appear that cancer is really not that difficult to cure. Urinary bladder cancer can be cured with asparagus. North American Indian bloodroot black salve(Thermopolis,Wy)is one used on skin lesions, including melanoma. In 2-3 days, the lesion turns hard and black, and in 5-7 days,the lesion falls out. If covered constantly with a heavy ointment as instructed, the area heals without a scar.
6. Diet is most important in cancer patients. I once heard a interview by a Mr. Housman, who puts about $100 million annually into a cancer treatment facility in Utah. He proudly stated that their kitchen was open 24/7 and a patient could have a steak or milkshake any time. I cringed. Meat and meat byproducts, including milk and eggs are terrible for cancer patients. Why? Not a single oncologist in the USA has ever read a book on molecular embryology. they believe the nucleus of the cell is the controlling factory of cell division. But if you read , you will find that in the blastula stage of the embryo, if you remove the connective tissue from the center of the 8 cell ball, all mitosis stops. If you put it back, mitosis(cell division)continues. Ah ha! It is the connective tissue of meat and related products that stimulate cancers to grow.
Secondly, cancer cells are more primitive that normal human cells and cannot process sugar into ATP efficiently. Cancer needs sugar. Remember the milkshake 24/7? Cancer cells can make about 4-6 ATP from one glucose molecule. Normal cells can make 24 ATP.
So if you want to kill a cancer patient quickly, give them meat, milk and eggs and sugar. If you want them to have a chance to survive, put them on a restricted diet, primarily vegetables and fruits.
I hope this helps someone.
Wonderful article, Dr. Murray. We should get the word out more to the public. My grandmother passed away last year and as the physician of the family I helped my extended family prepared for her last months and days. DNR, DNI. We called together extended family meetings and elected a spokesperson for my grandma, who did not speak English. Her doctor was very appreciative of our approach. We could all work together as a team. It can be done the more informed our patients are.
Tiffany Ho, MD
Psychiatry
In Tennessee, you can go to the State Department of Health website under “advance directives” and download several forms which need to be completed with appropriate witnesses or notarization and then shared with all of your doctors and your family. You also need to keep copies readily accessible.
A dear friend and health care professional suggested we do the Advance Care Directives in addition to the living wills we had already done.
When my husband fell and sustained serious head trauma, having the properly executed Advance Care Directive and an explicit living will allowed him to die with dignity and relatively quickly . . . without a lot of heroics and excessive care. His treatment (or lack there of) was carried out per his wishes. In addition, it relieved me of having to make life and death decisions at one of the most difficult time of my life. As the surviving spouse, I thank my husband every day for the gift he gave us both.
We have created a technological and chemical nightmare over the decades in the name sake of saving lives. I worked as an ICU nurse for over 25 years and witnessed more patients than I care to remember suffer through the last days of their lives. Suffering more were the families who were placed in a position of decision making about to pull the plug or not. What a horrible position we put family members in. Our medical profession needs support and education to practice medicine with more sensitivity to those who experience unnecessary suffering at the end of life – no matter what age or disease process. For just as doctors are trained to do all they can do to promote life, they also need to be trained in how to allow the natural process of death to take place without feeling they have failed.
Fantastic article. Thank you for bringing a new spin to a difficult topic. I hope to continue this discussion on my own blog. This is a very important topic. I have made my own wishes known to my family. I also recently cared for my dying father-in-law in my home, and he died very peacefully with my husband and I at his side. This was what he wanted–he lived well (even played tennis with us just 2 weeks before his death) and died with minimal suffering.
I have thought about this a lot, first at age 8, while jumping off a wall on the eve of my 9th birthday, suddenly realizing I would never be 8 again.
Written & published in 1994 as Editorial for Miami Medicine, reprinted in 2001 in the BMJ (British Medical Journal) as reply to their Editorial on the subject. Short — but too long for here.
The link:
http://www.bmj.com/rapid-response/2011/10/28/doctor-doctor-will-i-die
My mother, now 83 years old has laid out her wishes: do not resuscitate, no heroics, private funeral (family ONLY). She took care of my father for 10 years up until the time he died in 1986 at the age of 61. She did it out of love for him and when asked if she’d ever remarry, it was a definite NO.
I have been diagnosed with pancreatic cancer but mine is a rare form: non-endocrine, islet cell carcinoma. For me, dying right now is not a good option. My husband died almost 9 months ago and I have a son with Autism. I also have another son and the boys are ages 22 & 20. If I died sooner than later, I just don’t know how they would cope. They are barely coping with their father’s death.
I have been told I could survive 20 – 30 years with treatment. I’d be happy to split the difference and survive another 15 years, more than time enough for my sons to heal and learn true survival skills in the adult world.
I understand much better now how my OB/GYN let his cancer go for so long and only went to confirm his condition with another doctor when the pain he was enduring began to interfere with his efficiency as a OB/GYN. He tapered down his practice and arranged to have another doctor take over. He got his things in order and then quietly spent his last few weeks with his family. I had no idea he was sick until I read the news that he had died – ‘at home, surrounded by his family.’
When it is my time, I hope I go quietly into the night with my sons holding my hands as I leave.
Thank you for sharing your experiences. Too often families tell the doctors to do ‘everything’ they can and then when their loved one doesn’t survive, they are then looking at all the suffering he or she was put through, not to mention the huge hospital bill that needs to be taken care of.
Thanks for this thought provoking article.
My life has been full of meaningful coincidences! I am currently reading the book “The Tibetan Book of Living and Dying” by Sogyal Rinpoche. In the book, Sogyal spends a lot of time on the Buddhist traditions of preparing for death and allowing folks to die with dignity, in peace and in surroundings familiar and comfortable to them. The Buddhists have figured this out thousands of years ago and here we are still struggling with the idea.
I would humbly suggest that reading this book and understanding its profound messages could help us all in dealing with death and being sensitive and understanding in a deeply meaningful way. It has valuable lessons for the many roles we may play: doctors, patients, family members, friends and certainly as individuals who will ultimately die.
Thanks Dr. Ken Murray for opening & elaborating a important topic. This message should go to all physicians/Intensivist.
Its very well addressed. I will try to to spread the message in Indian community & may invite you to delever speech on it.
Very remarkable expressions.
Regards.
Jadhav Dr.
Thank you sharing what must have resulted in a personal catharsis.
My personal observations are the following:
1. Physicians can not effectively deal with death until they are
comfortable with death.
You would think that somewhere between gross anatomy, pathology,
and clinical rotations the nascent physicians would come to grip
with their own mortality, but I see this less often.
2. Not all intensivists consider deceleration of care the better
option.
I have had more than one intensivist professor of medicine in an
academic center tell me that their job is not to decide who will
live or die but to Trach,PEG, and Transfer to LTAC.
(When that $2M limit of catastrophic medical insurance is about
to be reached, the effort to achieve LTAC placement seems to
accelerate.)
3. When no one else will, one should step up to the bat, and take
the heat.
Too often, I, the consultant, have consulted palliative medicine
and opened a dialog with the family to discuss what they thought
the patient’s wishes would be and what the family members thought
of the current situation and possible medical outcomes.
Too often, the family has incomplete understanding of the
patient’s medical status and the factors at play limiting the
chance of meaningful survival.
3. The definition of meaningful survival must be defined by the
family if the patient is unable to do so.
I am never surprised when the providers’ definition of meaningful
survival and the family’s definition of meaningful survival is
incongruous.
4. Once the family’s definition of meaningful survival is known,
families are more capable of dealing with the setting of goals and
actions to be taken if goals are not met.
3. Hospice placement can provide relief to both the patient and
family.
The family of a patient entering hospice has the additional
benefit of receiving grief counseling for 13 months after the
patient’s death.
As the medical care within the US hospitals becomes more and more fragmented into shift work, I anticipate less resolution of an urgent problem.
One approach is obtaining an automatic palliative care consultation with in 72 hours of every ICU admission.
Unfortunately, few institutions have the resources to achieve this goal.
Also, in my experience, this goal has not been desired by the institution.
Perhaps JCAHO must require this to occur before it will occur.
Perhaps ACGME must require a palliative care rotation in all specialties to enlighten the physicians of their obligation to treat the end of life “for the good of their patients”.
A Lee wrote: “I really believe the fault is in the misperception at the societal level, that modern healthcare can deliver on miraculous things.”
Perhaps this is the crux of the disparity between the choices physicians make at the end of life, and those made by others. Doctors know the evidence, limitations and shortcomings related to treating terminal diseases like cancer, while other patients are more likely to have unrealistic expectations–fostered by media, well-meaning family and friends, and even health care providers. Patients rarely have the tools to evaluate health care claims, and thus are very vulnerable. In the name of “keeping hope alive” many are robbed of the chance to meet the end of their lives with clarity and dignity.
As a survivor of Hodgskin’s Lymphoma, I am grateful to all the physicians, researchers and, especially, the patients who endured treatments that ultimately determined a positive treatment for myself and others. I was only presented with one option: a cure, and 20 years on, it most certainly is. I consider myself fortunate for experiencing it and fortunate to have survived. As a teenager, I had too much living to look forward to.
However, if I was ever to face an illness like cancer again I would not necessarily choose treatment. For the same reason a Murray has discussed here. We know to much. We know the discomfort, the trauma, the side effects and the heartache. We respect people for choosing how they wish to live, but there is great dignity in choosing how we die.
Thanks to everyone for your posts, I read them all, and am greatly moved.
States vary, but for those who have asked about how to get a form for Advanced Directives or Living Will, in California we have a single form:
http://ag.ca.gov/consumers/general/adv_hc_dir.php
The link to the form is in the middle of the page.
Some have asked if there is actually data to support what physicians do. There is. I have an article coming out, which I’ll link to, that summarizes the studies. However, as a teaser, I ran a poll on the physicians-only discussion board associated with the Medscape website, asking if they would want CPR if they had a terminal illness that had exhausted treatment. 27 said no, 0 said yes.
Wonderfully insightful! I am a 59 year old retired family physician due to Multiple Sclerosis. In my 20 year career I have seen many cases where patients only existed; something I call “being unable to live but being unable to die.” They are unable to die because our drugs and machines won’t let them and they are unable to live because they are either riddled with a terminal disease and/or have no functioning consciousness. I agree wholeheartedly with dying with dignity. When my mother was found to be terminal, a wonderful and caring surgeon allowed my mother to die comfortably at my home, as was her wishes. I just finished all the needed paperwork to hopefully ensure I will be allowed to do the same. I don’t fear death…I fear what I have to go through before I die. I think it should be everyone’s right to die at home as comfortably as possible with dignity and with family by their side.
Everything happens for a reason, and there was a reason that I came across your article today. I am a 45 year old mother of two wonderful daughters and a loving husband. I am in stage 4 renal failure. I am not your average patient, I’ve done medical billing for 18 years..so I do know how much my care would cost the further it progresses. Sadly, because of choices I made early on in my life, my adult life has been plagued with hardships, financial difficulties etc. This year I chose to quit working and going out on disability because I needed life to slow down a bit so I could do some thinking. Your article surmizes what I have been thinking about for the past year…do I run up more bills for my family and our legacy? using up future descendants inheritance, or do I let things take their course and let things happen the way that they might. I refuse to live my life hooked up to a machine filtering out toxins in my body prolonging a life that has been riddled with pain. I choose to live the rest of my life, however long that may be absorbing the love of my family, the laugh of my girls, the blue skies and the green grass. I choose to feel the sand between my toes, the waves crashing over my head over sitting in a cold room hooked up to a machine performing functions my body can no longer perform. In the meantime I AM doing everything I can to prevent getting to that point where I will have to tell them, no, I won’t do dialysis..I walk every day, I eat pretty healthy, I read my Bible, I fill my days with love of my children and husband, and I LIVE my life. I know that THEIR lives will be better than mine because of choices I am making for them. Great article!
My father, a 65 year old incomplete C3-C4 quadriplegic for the prior five years, was admitted for a congestive heart failure exacerbation. After a sub-quality attempt to “tune him up” he deteriorated further and was intubated and transferred from his home town to the city, where he did not want to be. Fortunately, after 3 days, he was able to get off the ventilator and slowly found his way to the general floor. Myself, as an internal medicine physician, plead with the cardiologist and intensive care physician, for a palliative care consult. After several days, many calls and meeting, they conceded. Even the palliative care physician said, “he is not terminal.” I reassured them all with my professional experience and my close relationship with my father, that he was dying. 48 hours later, I meet with the hospice team and 36 hours after that, my father was released from his paralyzed body. I still five years later find it hard to believe my fellow physicians are afraid to admit they cannot “fix” someone and let them die with dignity and deny them the hospice care they deserve. Thank you for this article, so the conversation will be familiar and our colleagues will know that we should strive to be as good at providing care during the dying process as we are during the living!
Our family has endured several drawn out battles with cancer and chronic disease. Being a part of those processes from both a physician and family members perspective just reinforces that dying with dignity at home instead of depleting a life’s savings is the right choice.
This was perfectly done. So many people and patients fail to realize the limitations of medicine, the power of disease and therefore put off making appropriate end of life plans. My wife and I have clearly mapped out our individuals desires and agree to be bound by each others wishes as a matter of love and respect for each other.
Our family has endured several drawn out battles with cancer and chronic disease. Being a part of those processes from both a physician and family members perspective just reinforces that dying with dignity at home instead of depleting a life’s savings is the right choice. Life is for living.
My grandmother, who I was very fortunate to have in my life as a friend, mother and grandmother, for she was all of those to me died in a hospital bed. Even after many years I still feel the guilt and grief of not giving her the dignity of passing from our home. My husband and I had many discussions, laughs and gentle arguments with my grandmother who we both loved dearly. We were both aware of her wishes to DNR and not to extend her life by unnatural means. We made these known to the hospital staff quite adamantly, the only thing that I didn’t know that I could have done was to have had her moved to our home where she could have passed with us being by her side. Her one fear was that she would die alone or with strangers!
My husband and I have had our fair share of medical scares and have both decided to put in place a DNR if we are unable to speak for ourselves or each other. We have both lost someone dear to us because of Cancer and we don’t wish to suffer as they did or to allow each other to suffer the agonising withdrawal of personality that comes with the drugs administered to extend ‘life’
I agree with Ken Murray and most of the commenters: a hospital ICU is the last place you want to be when terminally ill. For those who are informed enough to make the transition, hospice and palliative care provide a wonderful alternative. However when it comes to pain management, even hospice is not always a panacea. In the better hospices, the only way to relieve acute terminal pain is by sedating a patient into a coma from which they never wake up. It’s also the only way to relieve the unbearable suffering of a patient who is suffocating and cannot find their next breath (Remember, no ventilators are allowed in hospice.) Hospices call this practice “palliative sedation.” After doing the research for my book, I discovered that the practice of palliative sedation in hospices is extremely capricious: you can’t really depend on it.
According to a 2010 report from the National Hospice and Palliative Care Organization, the practice varies between 1% and 52% in U.S. hospices. In other words, some hospices will do it all the time and others won’t do it at all. For a patient, it’s the pure luck of the draw. You can’t ask hospices ahead of time if they are going to sedate you. If you fall on a physician who does not agree with the practice, you could really get tortured at the end. Even in hospices that provide palliative sedation, the torture can last for hours. Why? Because the morphine is slowly titrated to a level that induces coma. They go slow to maintain a moral distance and not have it called euthanasia.
Unfortunately, a patient who is dying can greatly suffer during that “titrating” period. The numbers show that among hospice patients who were asked about their pain level one week before death, 5% to 35% rated their pain as “severe” or “unbearable.” An additional 25% reported their shortness of breath to be “unbearable.” This does not include other symptoms such as open wounds, pressure sores, confusion, vomiting, and emotional pain. And it’s twice as bad in ICU units.
Ultimately, you must do everything you can to protect yourself and your loved ones from a bad death. In our end-of-life system, it pays to have some form of “good death” insurance in the form of lethal prescription of sleeping pills—such as the ones provided in states where aid in dying is a legal option. Like any insurance the hope is that you never get to use it. Last year in Oregon, almost 40% of the patients who received a lethal prescription chose not to ingest it, but they died with the comfort and peace of mind of knowing it was available. Medically-assisted death, by whatever method, is palliative treatment: let patients choose what’s best for them.
Thirteen years of data collected in Oregon demonstrate that aid in dying complements hospice. By providing both, Oregon now has the best palliative-care system in America. Oregon leads the nation in the number of deaths occurring at home, effective use of pain medication, early patient referrals to hospice care, and improved quality of end-of-life care.
Robert Orfali, Author, Death with Dignity: The Case for Legalizing Physician-Assisted Dying ( http://www.DeathwithDignityBook.com).
This is an interesting article that addresses how doctors lead a less glamorous life than the preconceived notions we carry about doctors. Under the new regulations proposed under Obamacare, the future for doctors might even look less appetizing. I can’t wait to see what or if the administration’s healthcare policy becomes a topic on the State of the Union address tonight. Please see the article to reshape your notions of what doctors are and earn.
This is a good article with examples of desirable, or “good” deaths. Still, I beg people to not take the idea of “death with dignity” to the emergency room, especially if in a position to make life and death decisions on behalf of the patient. A story at the other end of the spectrum is that of my father, who did have a living will asking for “no code.” When camping he had a severe seizure and prolonged distressed breathing, all the time gasping to me “no doctors, no doctors.” I’m sorry, I didn’t think he was in any condition to make that decision and I called the EMTs who resuscitated my father on the scene and drove him hours to the nearest emergency room, stopping several times on the way to use the defibrillator. Long story short – my father survived this ordeal. It turns out he’d had a problem of long-standing, didn’t want to tell his doctor because he didn’t want any “medical intervention.” He got a pacemaker in the same ICU he went via EMT, and lived another 10 years. My mother thought he’d be angry at me for going against his living will and begging the EMTs and doctors to save him. The first thing he said to me after he came to at the hospital was, “I owe you one.”
If I gave in to the hysteria of my family members and the “death with dignity” rhetoric, I’d have allowed them to let me father choose to die when he was clearly not in a state of mind to make that decision for himself.
I think it is important to get an emergency patient stabilized, then make decisions about “quality of life” when everyone involved can get a clearer picture about what the future may involve.
As a surgical specialist of over 30 years I often witnessed the inhumanity of the intensive care unit in which terminally ill patients lives were prolonged at great suffering and expense. I am pleased to know that so many of my colleagues were and are also shocked by this needless and inhumane practice of futility. Thank you for your honesty and its resulting reassurance of faith in my profession.
I watched my Dad go through 4 years of Leukemia, from blood transfusions, bonemarrow transplants, chemo, “flag”, right down to watching him take his last breath. We didn’t know what we were heading into (really) and after watching from the side line, I’m not sure I could go through it for me or my family. The last weeks we had, was the same as the last weeks we would have had four years ago.. Really.
Wonderful article. Complements a website/book written by an emergency physician and her husband after a horrible experience with her father-in-laws final illness. For those of you looking for resources on HOW to make that decision, try this website:
http://oktodie.com/
I appreciate the intent of the article but want to point out that when prehospital CPR is initiated quickly in an otherwise healthy person who collapses and is unresponsive, and when that initial response is followed by early defibrillation and continued care by trained EMS responders and taken to the closest appropriate medical facility (apparently not USC), the results are likely to be more positive than the Dr. implies. In King County, Washington State, the ‘save’ rate for witnessed prehospital cardiac arrest is close to 50% – that’s walk-out-of-hospital alive.
Yeah, if I have pancreatic cancer, fire me up some medical ganga, bring in the family and let me go. But if I have heart disease and suffer an untimely death – work me up please. I’ll get my tattoo when I’m in my 80′s.
Well, yes to all of the above…but!!!
I’m in my 60s and (knock wood) in relatively good health. In a professional context, I’ve had occasion to work with many elders in various stages of living AND dying. I’ve done death watch for strangers and have listened to many lonely seniors insisting “I just want to die…”
I genuinely believe that the more important consideration is freedom of choice. Now, that may be a luxury enjoyed only by the wealthy (I’m not sure?), but I believe folks should be allowed to decide from a menu of options AND, more importantly, a change of heart (or mind) should be respected.
I’ve heard dedicated, loving daughters insist “Mom NEVER wanted extraordinary measures!” while the nurses aide who had been caring for Mom for the past several weeks (months?) has heard Mom repeatedly saying “whatever you do, DON’T unplug the machines!” I think of Elizabeth Taylor choking on a chicken bone–was her trach extraordinary?
I’m single, have very little in assets, no children and my only brother is on the other side of the U.S. I really don’t have a home or family I’ll want to go to to die…give me a nice, clean (teaching) hospital or nursing home bed.
Further, if everyone were to opt for hospice/palliative care (and, as a Cal/Oregonian–I’m definitely FOR it), how do the future docs learn? I want to be poked, prodded and medicated and I hope some young intern (and staff) will be watching & learning appropriately. And I’d just as soon NOT have family or friends watching, thank you.
BUT, most important, I want to reserve my right to change my mind–maybe several times? before I go.
I think the greatest value of this article is that it’s thought provoking AND has stimulated dialogue.
Cheers to Dr. Kervorkian, the godfather of controversy!
Its been a long time since we trained together as interns. I saw your article referenced in the newspaper and quickly pulled up your blog post on the internet. Well done essay on a timely topic. Keep up the good work. The word needs to get out.