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. This post was originally published at Zócalo Public Square, a non-profit ideas exchange that blends live events and humanities journalism.

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442 Responses for “How Doctors Die”

  1. rod williams says:

    I seriously doubt that anything in the universe has ever died, change is the constant and not total disappearance of the former.

    Human mammals do not want to give up their body, they want to continue being a mammal and some humans show great fear of no longer being so.

    Shedding our mammal body is natural, normal and necessary yet those who have been successfully brainwashed tend to fear something they have been taught to fear which is the word death. Yeah and a caterpillar dies too, right and don’t tear a Starfish in two and throw them back in the water.

    We humans reside in an infinite universe and that gives all life unlimited possibilities. Being a mammal forever sailing on a space rock around a star then counting the number of orbits we have made which gives the human their age so they know how to act is, well really mammal.

    We each are in the school of life and from it earn character and knowledge which contain the key to releasing our mammal body so that we can gravitate to a frequency more civil.

    Billions of human mammals have thus far shed their mammal body and not a single complaint. If we worry about losing our flesh then when we do, we will have done all that worrying for naught.

  2. rod williams says:

    “There ain’t no time to wonder why, yippee we’re all gonna die” – Country Joe McDonald, Fish Cheer.

    • rod williams says:

      We really need Dr. Kevorkian, many like him actually and it’s a shame that since what we mammals call death is natural as well as necessary, too bad we are not yet intelligent enough to accept and make it a fun positive occasion.
      The human herd of mammals overall are the most destructive on the planet which makes us the most ignorant. We are born into a dimension that is insane and live our lives. War is the most insane act that a human mammal can do, all humans on the planet, past, present and future are blood related and war is the prime way to solve our problems.

      A part of the problem is that we believe that we are intelligent and have dominion over all life yet, our book say that we are and we have been programmed to believe the printed word.

      The highest goal I see for any species of life who live on a piece of spinning space rock is to give our children a good place to be born. In order to do that all war would have to end worldwide. Unfortunate that our parents were not more intelligent. Sad really.

      I went into physical shock from pain in 1988 from an abscess, had a tooth ache one Friday night after arriving home from work, decided to wait until Monday morning as dental prices would be less. By Saturday night I was in much pain so I smoked female cannabis to help me control the pain. I again woke up early Sunday morning and the pain was really bad. I became hot and turned a fan on my and lay down in bed and very soon I became cold, very cold and it was all I could do to pull covers over me and place a pillow under my feet in order to get more blood to my head.

      The next thing I remember is feeling wonderful and a floating sensation, neither was it dark or light, there was no pain. Felt like my feet were shutting down and working its way to my brain. I didn’t mind, I had accepted shedding my flesh in 1977 after running from the thought of death in May of 1969, ingested some San Francisco LSD while living in New Orleans, On that trip Death came to me and said that it was time for me to go, I was laying in the back of my VW van in the New Orleans French Quarter and here Death wanting to take me, My thoughts were, there must be some error, others die, I don’t. LOL

      I ran, I drove from there to Phoenix spending 1 night at a rest area in Texas, the next night I was back in Phoenix. Death still followed me especially after dilating my blood vessels with female cannabis bud so I slacked off on that for almost 7 years then had enough carrying this fear of no longer being a mammal so I smoked a bowl of pot throwing caution to the wind and realizing that Death will come for me again and when it did, I with every atom in my being accepted it and I had an emotional climax that was so wonderful and lasts to this day.

      Then in the summer of 04 I woke up preparing to do some chores on that Saturday morning and I did not feel quite right, my head felt swirly and I was tired even though I had just awoken, Strange I thought, something is happening to me that has never happened before, wonder what it could be I thought? My wife was trying to get me to go to a hospital as she knew that something was up as I did not look very well to her, I assured her that all I need was sleep and I’d be fine. At that point in my life I had orbited our sun 62 times, was born in 1942 and mom had a brain aneurysm a decade earlier and died, The thought of death while this was happening didn’t bother me at all. No concern. Her and a son in law who lived across the street took me to a hospital and they examined me, placed me in an ambulance with lights and sirens and took me to Barrow Neurological about 5 miles away, I remember none of this, I misplaced 6 weeks of memory from my life due to the aneurysm in the basilar region of my brain. I had one of the top brain surgeons in the world treat me, clipped my bleeder with a tool that he invented, Dr. Robert Spetzler. I heard later that he had stopped in to his work to say goodbye as he was leaving for a vacation. Sorry but thanks for the clip.

      At 6 weeks and 99 lbs, down from 131 the hospital advised my wife to place me in a suitable home as I had no memory yet I was awake and was told by friends that I seemed like I was only partially there from those who had visited. That same night in a pitch black ward of moaning people my memory made a connection and I knew who I was, where I was and why I was there. My problem I had to pee really bad and was locked down in a nylon webbed bed and could not get out. I buzzed, yelled and screamed a few times to attract anyone who could help me but there were no takers.

      I wadded up a top sheet tightly and stuffed it in the bottom corner of the bed and used it to pee on then went to sleep which was easy. Next morning a staff noticed I had remembered something so they kept me another week, gave me an appointment for 3 years down the road and sent me home with a bottle of Dilantin. Dilantin side effects are not very pleasant and are in fact dangerous but they do dilate blood vessels.

      On the other hand a University study during that period showed that cannabis also dilates our vessels and makes a good stroke preventer, much better than the chemical capsules and without any dangerous or unpleasant side effects. The very first thing I remember anyone saying to me once my memory made a connection was that I needed to eat solid food or I would be put back on the feeding tube. As 1 of Dilantin’s side effects it takes away the users senses of taste and smell so my food didn’t have a taste or smell, all I could discern was how warm it was. Had they given me cannabis I would probably have eaten the cafeteria out then asked for more.

      I cancelled my 3 year appointment, didn’t have the 1000 dollars to have dye injected into a vein then scanned. While awaiting surgery the staff wanted my medical history, we’ve had the same family doctor, a really good physician and surgeon for over 35 years and my history went back 35 years for a hemorrhoid which the good doctor explained to me how I could eliminate it on my own. That was it, colds and other sicknesses were rare with me but then I feel that my eating habits had the most benefit to my overall health which was eating my first meal of the day after working my ass off on my job. I ate good and lived off stored enzymes as do the large jungle cats and such though they average 2 meals per week and can go several weeks and still have that burst of speed to catch a meal.

      When the cat has had 2 meals, we humans according to our program what we have been taught have had 22 meals plus snacks. I ate my first meal of the day in the evening not becoming hungry once I became accustomed to my stomach sending aches and pains to my brain and then no hunger at all. I did this for over 30 years and when I have a lot of chores or work to do I can easily do it again. I can maintain a very positive energy flow and keep working without breaks while those who are food addicts go bananas and start shoving things into their mouth. This happened to me by accident, that a good friend had a triple bypass and I took his business over as well as my own for 17 weeks and I just didn’t have time to eat. Took a week, I forget how long but the hunger pains went away and I felt like a superman and never really became sick,

      Food is a killer. That’s my .02¢. Being a mammal is temporary, be glad, be very glad,

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  4. Shally Arora says:

    ever wonder what a doctor goes through when he realizes his mistake

    http://healthcarekm.wordpress.com/2014/04/06/the-pain-of-missing-the-pain/

  5. Julie Andre says:

    I just read this article in the July issue of Readers Digest. I can not tell you how it affected me. I am 63, in relatively good health and I agree 100% with Dr. Murrays attitude.I witnessed my beautiful Aunt, who had an aneurysm hooked up to life support where she stayed for months. This once 95 lb woman ballooned to almost 250 lbs during this time. Her family fought very hard to get her taken off, but, once on, hard to get off. I want to die EXACTLY as outlined in Dr. Murray’s article. I have told everyone in my family, my good friends, everyone I can reach of my wishes. I do not want CPR, I do not want to wind up an invalid for the rest of my life. I’d like to die in peace in my own home and pass quietly to the after life

    • John Ballard says:

      Two years and over four hundred comments later Dr. Murray’s article continues to affect many people. Very impressive.
      And yes, Julie Andre, you’re right.
      ** Follow up by getting the proper advance directive forms for your state, get them properly filled out and witnessed.
      ** Decide at least three agents to be appointed to make medical decisions on your behalf in the event you are unable to communicate.
      ** Make sure they know who they are and have agreed to the responsibility.
      Put your advance directives where they can be easily found if needed. A file copy with your PCP is a good idea.
      ** Follow up every three to five years to be sure your agents are still available and have not changed their minds. Take that opportunity to read over what you said in light of medical changes that may have happened since you last checked — in case you change your mind about anything.
      ** I have heard that in some places the same individual is not allowed to be an agent for medical decisions and also have POA for the estate or other matters. I’m not a lawyer but that is a detail to check into.
      **And finally — pass the word…

  6. Paul says:

    “Never, Never, Never Give Up.” Winston Churchill.

  7. Shiwani says:

    This is a great article, and it gave me a lot of ideas.
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