Doctors Die Differently

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Many years ago, my late father received a recommendation for carotid artery surgery. He had no symptoms, but his physician was concerned about kinking and possible narrowing of the artery. I described the situation to a vascular surgeon colleague. He thought the recommendation was questionable. I encouraged my father to talk further with his physician about the procedure. In their discussion the physician said, “I’m a worrier — I would do this for myself. But now that I hear more about your values, I don’t think you should do it.”

This exchange should have occurred before the recommendation was made. But the physician was commendably self-aware and honest. (The artery never caused problems. My father died years later, at 89, of other causes.)

When I was in clinical practice, patients sometimes asked me what I would do if I were in their situation. I thought this was a reasonable question. Interest in how our physicians care for themselves is more than idle curiosity. Their choices don’t establish “truth.” But knowing how they handle their own care and the values they bring to bear on their choices is useful “data” for our own reflection.

In a Wall Street Journal article, “Why Doctors Die Differently,” Dr. Ken Murray, a retired assistant professor of family medicine at the University of Southern California, told how a physician mentor and a cousin both chose “low tech” end of life care for themselves. Dr. Murray cited a study of elderly graduates from Johns Hopkins Medical School that supports his anecdotes — a large majority would refuse a range of life-sustaining treatments. Here’s how Dr. Murray put it:

It’s not something that we like to talk about, but doctors die, too. What’s unusual about them is not how much treatment they get compared with most Americans, but how little. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care that they could want. But they tend to go serenely and gently.

Doctors don’t want to die any more than anyone else does. But they usually have talked about the limits of modern medicine with their families. They want to make sure that, when the time comes, no heroic measures are taken. During their last moments, they know, for instance, that they don’t want someone breaking their ribs by performing cardiopulmonary resuscitation (which is what happens when CPR is done right).

Dr. Murray speculated that when patients ask their physicians how they would handle their own end-of-life care, we physicians are reluctant to answer. Though I haven’t seen any research on the issue, his guess could well be right. End-of-life care involves the most personal choices we make, and we physicians might hesitate to reveal our own values out of a fear that we would exert too much influence on our patients.

But it’s also possible that we’re simply reluctant to discuss something as personal as our own end-of-life preferences. Good medical care, however, requires conversations of this kind, and I believe we should be prepared to share our personal values with patients if that sharing could help them in their own thinking.

All too often overly intrusive end-of-life care happens by default. As a symptom of our pathological political culture, a proposal to reimburse primary care physicians for discussing their patients’ values for end-of-life care elicited a) an accusation of “government death panels” from duplicitous politicians and b) a mini-epidemic of public paranoia.

James Sabin, M.D., 73, is an organizer of Over 65 and a clinical professor of psychiatry at Harvard Medical School.

4 Responses to “Doctors Die Differently”

  1. JJerome Medalie ( J.D.,86, Sponsor of The Jerome Medalie End-of-Life Issues Study Group, Bioethics Center, Yale University)

    My compliments for your choice of subject and your candor in discussing it.
    One reservation: the word “commendably” in “But the physician was commendably . . . honest.” was jarring. Honesty is the least a patient should expect from a physician at end-of-life (EOL). I also believe the motivations or causes for lack of communication at EOL or disinformation are more complex and diverse than you or Dr. Murray suggests. I would welcome a full, frank discussion of this assertion, ranging from medical schools’ failure to teach in this area to the impact of religious beliefs on EOL care to the observation by Time’s award-winning and highly esteemed journalist Joe Klein, uttered following the deaths of his parents, to the effect that we will not achieve a health care system which provides peaceful, dignified deaths so long as the reimbursement mode is “fee for service”: see The Long Goodbye” Thttp://www.time.com/time/magazine/article/0,9171,2116137,00.html?pcd=pw-hp and video. The conflict of interest issue and the prevailing absence of comprehensive “best practice” guidelines constructed by doctors for EOL care should be discussed in this context.

  2. Faye Girsh

    I have always suspected that doctors also use their access to barbiturates and large doses of opiates to peacefully end their lives when they realize their quality of life is unacceptable and nothing more, that is acceptable, can be done.

  3. Peter Rogatz, M.D.

    Yes, physicians die differently (by avoiding the technologic intrusion which is so often the default position). A more peaceful, less intrusive end will not become a widely accepted pattern until there is a cultural shift among both physicians and lay persons. As Dr. Sabin notes, the irrational response to the proposal that Medicare reimburse for discussion of patients’ end-of-life values tells us that such a cultural shift has yet to occur. I hope the proposal can be reintroduced with the support of respected groups (including, perhaps, the Hastings Center?) in a way that avoids the paranoid fear that it is a device to save money. That would be a major step forward.

    • Jim Sabin

      Dear Jerome, Faye, and Peter –

      Thank you for your thoughtful comments. I’ll reply in sequence.

      Jerome – I agree completely that honesty should be an ordinary expectation, not a commendable exception. I meant to be emphasizing my father’s physician’s self awareness – that he was a worrier and my father wasn’t. I do think that kind of (a) self awareness and then (b) personal disclosure are distinctive and commendable. Thank you for the link to Joe Klein’s superb article. It brought tears to my eyes. I sent the link to my oldest grandchild, who’d recently sent me a link to the Murray article. (I’d already read it, but I loved the fact that my first year college student grandson found it and thought I’d be interested.)

      Faye – access to barbiturates isn’t as easy as it was 25 years ago, but I’d guess that you’re right that doctors may use their access to medication for themselves the way physicians in Oregon and Washington are able to do for patients with terminal conditions. It would be difficult to do research on your hypothesis, but worthwhile to try.

      Peter – I agree that a cultural shift is required to move our society away from the default position in favor of excessive “activism” at the end of life. I believe that shift is underway. It’s not going to happen quickly in a country with more than 300 million and a political tradition of vociferous attack, as we saw with the “death panel” absurdity. The article by Joe Klein that Jerome gives a link to illustrates the kind of communication between doctors and patient/family that’s required to prevent the kind of technological hectoring that we see all-too-often at the end of life.

      Best

      Jim