Seventy-five Year Old Doctors Talk about Death

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Here’s what George Eliot wrote in Silas Marner about how the elderly contemplate the prospect of death:

“…it is often observable, that the older a man gets, the more difficult it is for him to retain a believing conception of his own death.”

I observed the opposite at my fiftieth medical school reunion in June.

In a multitude of conversations, and in the entries classmates wrote in our reunion book, we displayed a vivid “believing conception of [our] own death(s).” No one I spoke with was morbid. No one evinced fear.

The dominant tones were (1) matter-of-factness, (2) gallows humor, and (3) curiosity about the future of our species and planet.

Some of the matter-of-factness certainly comes from our being physicians. We’ve cared for people at the end of their lives. We’ve attended patients’ funerals and memorials. We’ve seen a lot of death up close. But I believe that much of our matter-of-factness simply came from our age. We knew the actuarial predictions. The average 75 year old man will live 10.89 years. The average female (there were only 5 women in a class of 140) will live 12.77 years. Talking about our 55th reunion, in June 2019, when most of us will be at least 80, one of the organizers said the obvious – “we’ll be a smaller group.” Another classmate was more precise: “the actuaries calculate that only half of us 50-year survivors will be here to celebrate our 60th reunion.”

We were realistic about mortality, but that didn’t mean we liked what was coming.  We used humor to tame fear and anticipated loss. One classmate put it wryly: “This one [the home recently moved to] seems destined to be the last one. I find this alternately reassuring and unsettling to think about, depending on my mood of the day.” Another went all the way into gallows humor:  “When they put the tag on my toe I will be retired. Just prior to the cremation and just after they notice I don’t have a pulse.” More than one, when asked “how are you?” responded with a version of “at least I’m looking down at the grass rather than up from under the ground!”

The third pattern I observed – in others and in myself – was curiosity about the future and hope that the next generations will be able to solve some of the problems that have thrown us for a loop. Many of us wished we could come back in 50 or 500 years – not for reincarnation but simply to see what was going on.

Starting in medical school we’ve seen how technologies can keep the body going long beyond the “natural” time for life to end. That’s why so many of us don’t want over-zealous interventions from our own physicians.

In a 2012 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 [this isn’t what I observed at my 50th], 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).

As a 26 year-old starting my residency in psychiatry, I was startled when our training director asked a depressed elderly patient “where do you want to be buried?” and even more startled when the patient  perked up and spoke from his heart, with comfort, about life and death. But a 26 year old starting residency in 2014 should be smarter than I was in 1965. Multiple research studies have shown that what researchers call “death anxiety” declines with age, and is lowest among the elderly, and students are taught how to talk about death while still in medical school.

Every reader of obituaries knows it’s de rigeur for the dead to have “fought valiantly” against the illness they ultimately die from. American culture is more about “fighting illness” than acknowledging mortality. An old joke speaks to the world view behind all our talk about fighting illness: “In India, death is seen as a potential step away from reincarnation and towards Nirvana. In Europe, death is seen as an existential tragedy we all must face. In the U.S., death is seen as optional.”

The punch line of the joke may apply to young invincibles, but by the time they’re over 65, they, like my medical school classmates, will have concluded that death isn’t optional!

Jim Sabin, M.D., 75, is an organizer of Over 65, a professor of population medicine and psychiatry at Harvard Medical School, and a Fellow of the Hastings Center.

 

8 Responses to “Seventy-five Year Old Doctors Talk about Death”

  1. Rex Greene

    Jim,
    As someone a few paces behind you I share your views. One particularly annoying issue you highlight is the obligation to “battle” one’s diseases. War as metaphor is the worst way to frame deep questions of life and death. Quite simply war is an evil, obsolete form of problem solving that has no applicability to anything. Mankind should have dedicated the current millennium to ending war forever. War is humanity at its worst, socialized murder, depravity that begets itself in cycles of violence. How then can it metaphorically promote healing, the restoration of wholeness? (One can be healed and die in the next moment). In its most callow version it becomes a perverse sporting event with winners and losers. Well, my disease is me. Not being schizophrenic (in the old meaning) I choose not to declare war on myself but embrace who I am so that I may cope with whatever comes my way. Currently it’s the miscellaneous infirmities that accompany a 70th birthday. Moreover, one need not engage in warfare to seek forgiveness and reconciliation. As a product of the 60’s I had rather hoped for more from my generation. Maybe in our dotage we will once again embrace the optimism and idealism of our youth. I too am curious to see how it all turns out.
    Rex

    • James Sabin

      Dear Rex

      First, I want readers to know how grateful I am for the gracious way that you, as chair of the American Medical Association Council on Ethical and Judicial Affairs, welcomed me as a newcomer to the Council two years ago and taught me the ropes. Thank you again!

      And, thank you for the very thoughtful analysis of what’s wrong with the metaphor of making war on our illnesses. With regard to illness, the opposite of “fighting” isn’t “craven surrender” – it’s more like “thoughtful response.” If our illness is treatable and our aim is to stay alive, we should work at recovery. If our illness isn’t treatable, or if we’re ready for terrestrial life to end, we should accept what comes. Your point that war is not the same as healing says it all.

      Best

      Jim

  2. Louise Dotter

    Excellent article and comments – now if you and your other colleagues on the AMA Council on Ethical and Judicial Affairs would PLEASE convince the American Heart Association and various other CPR evangelists to expand their 2 Steps to Save a Life campaign. Between Step 1 “Call 911” and Step 2 “CPR” they need to include a check for DNR/POLST instructions (bracelet, tattoo, wallet card etc) BEFORE starting CPR. I swear I’m going to have a tattoo on my damn forehead that says NO CPR u do I SUE!

    • Jim Sabbin

      Hi Louise
      Unfortunately, your concern is all-too-realistic. If the person with POLST instructions is living with others, the “other” can do what you picture the tattoo doing. The kind of education that’s called for happens best locally and regionally. I hope that learning progresses enough so that you no longer feel you need a tattoo or a neon sign!
      Best
      Jim

    • Carol Eblen

      I disagree! Better to err on the side of saving a life than delay and kill a patient because the paramedics are looking for a DNR authorization.

      The Congress hasn’t clarified the law of the 1991 PSDA that implies that there is a right to die, to refuse treatment and to shorten one’s life, and also a right to live when one is hospitalize in an emergency,if this is one’s desire. The ABA did offer an opinion that the 1991 PSDA would permit Medicare to withhold reimbursement for treatments that were in violation of advanced directive authorized in the 1991 law.

      However, The Congress still didn’t clarify the PSDA for the States. Apparently, they would have had to clarify the meaning of the “discrimination” in code status that is prohibited in the PSDA and they didn’t want to do this, did they?

      Is the targeting of the elderly/disabled/poor etc.. on Medicare/Medicaid for end-of-life savings by means of managed care and managed death and unilateral DNR Code Status really necessary to save Medicare?

      The “push” by the powers that be to require advanced directives is biased toward shortening life/hastening death for the fiscal expediency of big Insurance who has invaded the people’s social safety net, Medicare and Medicaid.

      The epidemic of unilateral covert and overt DNR Code status in our nation’s hospitals that is a reaction to the “managed care” and “managed death” reimbursement protocols of Medicare and the Advantage Insurers is a national disgrace.

      It appears that “choice” to live is removed in favor of hastened death to protect private profits.

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