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December 16, 2011

The Final Chapter

http://www.jewishjournal.com/blog/item/the_final_chapter/

“Soon I will rest, yes, forever sleep. Earned it I have.”—Jedi Master Yoda

I have some bad news for you. You’re going to die.

Not soon, I hope. But for the foreseeable future the death rate will remain one per person.

This week a patient pointed me to a wonderful article by Ken Murray, “How Doctors Die”. Dr. Murray, a USC Family Medicine physician, argues that doctors faced with terminal illnesses very frequently forego aggressive care and die peacefully at home, while other patients are subjected to invasive, painful, and futile care at the end of life. I urge you to read the article. In fact, you might want to read it first and then return to this post.

All doctors have seen cases of patients receiving invasive, aggressive, futile care. Some cases involve not just care that is unlikely to help, but care that has been shown in studies not to help, like feeding tubes placed in patients with dementia, or CPR performed on patients dying of cancer. This is a calamity because it subjects patients who are frequently frail and in the final days of their lives to gratuitous suffering without any potential benefit. Worse, as if the suffering of the patients’ disease was not bad enough, the suffering due to futile care is inflicted by physicians. Though Dr. Murray also highlights the astronomical cost of futile care, I think the economic argument is unnecessary and counterproductive. These cases are a calamity even if the care was free. Patients should understand that we are appalled at such outcomes because of the harm done to patients, not because of the wasted resources.

Dr. Murray describes the problem well and recommends the path frequently chosen by physicians when they themselves are ill – hospice care, a focus on quality of life, and death at home. But how do we convince patients that this is best? Many patients believe that medical technology is omnipotent, and that recommendations for hospice care amount to giving up. Other patients, bewildered by the complexity of healthcare delivery, suspect that doctors have a financial motive to withhold lifesaving care. These misunderstandings can only be reversed if there is trust between patient and doctor.

Doctors, of course, share much of the blame. Ordering another test, recommending another procedure, and prescribing another medicine are all easier than giving a patient and her family terrible news. Maintaining a false hope is easier than explaining that this illness will be the last.

The best patients can do is to tell loved ones their wishes in advance, and develop a long-term relationship with a doctor they trust.

The best doctors can do is be honest when things are dire, and recommend against futile care with patience and compassion.

“May you die well.”—Klingon benediction

Learn more:

How Doctors Die (Zócalo Public Square)

My previous posts about end-of-life care:

When Less Care is More

A Dose of Realism about Advanced Dementia

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor.

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