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.